ADVANCE implementation of the PCORnet Common Data Model (CDM), Version 3.0

Transcription

1 implementation of the Common Data Model (CDM), Version 3.0 Last Updated: April 26, 2017 Contents 1. Overview of Introduction Background Research Data Warehouse and Common Data Model v3.0 Diagram CDM Design Topics General Design Considerations Comments on Protected Health Information (PHI) Individual Table Specifications Table: DEMOGRAPHIC Table: ENROLLMENT Table: ENCOUNTER Table: DIAGNOSIS Table: PROCEDURES Table: VITAL Table: DISPENSING Table: LAB_RESULT_CM Reference Table 3: Laboratory Standard Abbreviations Table: CONDITION Table: PRO_CM Reference Table 4: PRO Common Measures CDM Page 1

2 3.11 Table: PRESCRIBING Table: PCORNET_TRIAL Table: DEATH Table: DEATH_CAUSE Table: SURGICAL HISTORY ( only) Table: HARVEST Table: Immunization Table: FAMILY_LINKAGE Appendix A: Glossary of Terms Appendix B: Community Vital Signs (CVS) Appendix C: Data Completeness Summary Appendix D: Patient Distribution by Clinic's State Appendix E: Selected Patient Characteristics Appendix F: RDW Data Completeness Summary Supplemental RDW tables (for internal analysis) Table: PROVIDER_CROSSWALK Table: NPI_TAXONOMY_CLASSES Table: CMS_HEALTH_CARE_FACILITIES Table: HRSA_HEALTH_CENTER_SITES CDM Page 2

3 1. Overview of 1.1 Introduction The Accelerating Data Value Across a National Community Health Center Network () Clinical Data Research Network (CDRN), funded by the Patient-Centered Outcomes Research Institute (PCORI) CDRN , horizontally integrates outpatient electronic health record (EHR) data for safety net and federally qualified health center (FQHC) patients, and vertically integrates hospital, health plan, and community data for these patients. 1 The CDRN serve as a community laboratory for engaging vulnerable patients in Patient Centered Outcomes Research (PCOR). 1.2 Background PCORI s National Patient-Centered Clinical Research Network, called was created to improve the nation s capacity to conduct comparative effectiveness research by creating a large, highly representative electronic data infrastructure for conducting clinical outcomes research. consists of: 13 Clinical Data Research Networks (CDRNs), such as 20 Patient Powered Research Networks (PPRNs) 1 Coordinating Center, 11 Task Forces Governed by an Executive Committee, Steering Committee, and Patient Council is led by OCHIN s Practice-Based Research Network in partnership with Health Choice Network (HCN) and Fenway Health. We are: A network of over 129 community health center (CHC) systems Building a community laboratory of CHCs with longitudinal outpatient clinical data on patients seen since 1/1/2012 (see Figure 1) Forming strategic partnerships with health plans and hospitals that will bring inpatient data into existing outpatient data repository Bringing in community-level data to help assess environmental/external factors that impact health Currently the data repository contains ambulatory data from three ambulatory data partners (OCHIN, HCN and Fenway), hospital data from Legacy Health, claims data from CareOregon, and geography-based community-level data from the Robert Graham Center (see Figure 2). CDM Page 3

4 Figure 1. Data Approach Figure 2. Current Data Partners and Source Systems. C10 Coordinating Center - OCHIN CDM Health Choice Network Ambulatory Data Data Source: Intergy OCHIN Ambulatory Data Data Source: Epic Fenway Health Ambulatory Data Data Source: Centricity Legacy Health System Hospital Data Data Source: Epic Robert Graham Center / Health Landscape Geography-based community data Data Source: Geospatial data system CareOregon Claims Data Data Source: QNXT CDM Page 4

5 1.3 Research Data Warehouse and Common Data Model v3.0 Diagram CDM Page 5

6 2. CDM Design Topics 2.1 General Design Considerations Prioritization of Analytic Functionality The CDM is designed to facilitate routine and rapid execution of distributed complex analytics. To meet this design requirement, some fields are duplicated across multiple tables to support faster analytic operations for distributed querying. The CDM is based on the FDA Mini-Sentinel CDM ( MSCDM ). This allows to more easily leverage the large array of analytic tools and expertise developed for the MSCDM, including data characterization approaches and the various tools for complex distributed analytics. The Research Data Warehouse and Common Data Model The Research Data Warehouse (RDW) contains all tables and fields defined for the Common Data Model (CDM) plus additional fields that the CDRN requires for research purposes. These fields are elements unique to safety net clinics that collect data for UDS and other CHC-related reporting purposes, which are typically not collected by non-chc clinics. These fields include Federal Poverty Level, patient primary language, migrant/seasonal worker status, homeless status, and so on. Date Formatting The CDM always separates date fields and time fields for consistency, and employs a naming convention of suffix _DATE or _TIME. All times are recorded within the local time zone. Missing or Unknown Data Values The CDM uses the HL7 conventions of Null Flavors ( as a basis for representing missing or unknown values. Specifically, for fields where an enumeration is present (i.e., a categorical set of values), null values are represented as follows: Missing unknown data CDM field value CDM Meaning A data field is not present in the source system NULL Null value A data field for an enumeration is present in the source system, but the source value is null or blank A data field for an enumeration is present in the source system, but the source value explicitly denotes an unknown value A data field for an enumeration is present in the source system, but the source value cannot be mapped to the CDM NI UN OT No Information Unknown Other This representation CDM is only applicable for categorical text fields, not for numbers or dates. Page 6

7 Source Data Consistency: By design, the CDM does not include data consistency rules or edits, such as upper and lower limits of numeric values. The value recorded in the originating source system is populated in the CDM, even if the value is outside a normally acceptable limit. Inclusion of all originating data, without modification, supports data characterization and better data provenance. Decisions about inclusion (or censoring) of outlier values will be made as part of each analysis or query, allowing for these decisions to be driven by appropriateness for each individual analysis. The CDM normally reflects variables and values found in the local data. In some cases data are coded in a way that is unique to a site, thus mapping the data to a standardized format is necessary. Values in the source data before mapping are generally also included in the CDM. Derived variables are avoided. Raw Fields The data model uses a convention for raw data fields. These are optional fields for storing the originating source value of a field, prior to mapping into the CDM value set. These are also used for source-specific ontologies. The RAW fields are intended to support data provenance and facilitate quality control checking by local implementation, if desired. These fields will have a naming convention of prefix RAW_. Case Sensitivity: The CDM is not case sensitive. Incomplete Dates: There are situations where the exact day or month is unknown or not available, and it is still necessary to have a valid date for native RDBMS and SAS date data types. The following imputation strategy is used to address this situation: If the day is missing, the first day of the month is used to create a valid date value with the existing month and year. If the month is missing, January 1 is used to create a value date value with the existing year. The REPORT_DATE in the CONDITION table for medical history diagnosis records is an example of date imputation. The corresponding date may be captured in a free-text field in the source EHR where dates can be entered as complete dates, partial dates or comments, or this information might be missing. The HARVEST table indicators of DATE_ fields are used to indicate the presence of incomplete dates within the data. If available, the RAW_ fields are also used to indicate the presence and original value of incomplete dates. CDM Page 7

8 2.2 Comments on Protected Health Information (PHI) The CDM contains some of the 18 elements that define PHI under HIPAA, including encounter dates and date of birth. To maximize analytic flexibility and allow for all types of analyses, complete and exact dates are included in the CDM. Distributed analytic programs will use the date fields for analysis, but will generate results that contain the minimum necessary information to address the question. The results returned to the requester are typically aggregated and do not include any PHI. Queries that generate results sets with PHI (e.g. a person-level analysis under an IRB, with all necessary data agreements in place) are clearly flagged as such and will only be distributed with the appropriate approvals clearly documented. As with all distributed CDRN queries, staff will review all results before release. Pseudo-identifiers: As part of the de-identification process of the CDM, replaces the original identifiers on sensitive or confidential fields with arbitrary pseudo-identifiers, the crosswalk tables that contain these mappings are by design not part of the CDM, and access to these tables is limited to authorized staff. de-identifies the following fields in the CDM: PATID is a pseudo-identifier with a consistent crosswalk to the true patient identifier in the source system, these pseudo-identifiers do not change between refreshes. Pseudo-identifiers are only generated for newly added patients. If records are merged in the source system, the corresponding crosswalks are updated accordingly. PROVIDERID is a pseudo-identifier with a consistent crosswalk to the true provider identifier in the source system. This crosswalk is consistent between refreshes. FACILITYID is a pseudo-identifier with a consistent crosswalk to the true facility identifier in the source system. This crosswalk is consistent between refreshes. ENCOUNTERID is a pseudo-identifier with a consistent crosswalk to the true encounter identifier in the source system. Due to the changing nature of these values in some source systems, this crosswalk is currently not consistent between refreshes. CDM Page 8

9 3. Individual Table Specifications 3.1 Table: DEMOGRAPHIC DEMOGRAPHIC Domain Description: Demographics record the current direct attributes of individual patients Relational Integrity: The DEMOGRAPHIC table contains one record per patient. Primary Key: PATID Field constraints: PATID (unique, required, not null) Inclusion: All patients with at least one medical ambulatory encounter ( AV encounter type) on or after 1/1/2012 (start date established by ). Exclusion: Known test patients. Infants less than 31 days old at the time of the data extract. Additional Notes: This table contains the most recently available patient information at the time of the data refresh. ICD 9/10 codes for all chronic condition Y/N columns can be found in the _RDW.dbo.CHRONIC_CONDITION_DX_GROUPERS table (see table documentation below, section 4.5). CDM Page 9

10 DEMOGRAPHIC Table Specification Field Name SQL Predefined Value Sets and Descriptive Text for Categorical Fields Source PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. PATID is a pseudo-identifier with a consistent crosswalk to the true identifier retained by the source data partner. For analytical data sets requiring patient- level data, only the pseudo-identifier is used to link across all information belonging to a patient. The PATID must be unique within each data mart. The PATID is not the basis for linkages across data partners. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. OR_MEDICAID_ID Int. Oregon Medicaid number OCHIN_EMPI Int. Patient level identifier from the source system. Can be used to lookup patient in EPIC hyperspace. Applicable to OCHIN/EPIC only. SAS_BIRTH_DATE Int. SAS data value. Represents the number of days between January 1, 1960, and the patient s birth date. BIRTH_DATE Date. Date of birth. BIRTH_TIME varchar(5): Format as HH:MI using 24-hour clock and zero-padding for hour and minute. Time of birth. Source of time format: ISO 8601 CDM Page 10

11 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical SEX nvarchar(2) A=Ambiguous F=Female M=Male NI=No information UN=Unknown OT=Other Administrative sex. The Ambiguous category may be used for individuals who are physically undifferentiated from birth. The Other category may be used for individuals who are undergoing gender re- assignment. Source Source: Administrativ e Sex (HL7) ds.cdc.gov/v SEX_DESCRIPTION varchar(50) See values above Description of sex. ads/viewval SEXUAL_ORIENTATI ON char(2) AS=Asexual BI=Bisexual GA=Gay LE=Lesbian QU=Queer QS=Questioning ST=Straight SE=Something else MU=Multiple sexual orientations DC=Decline to answer NI=No information UN=Unknown OT=Other Sexual orientation. FederalRegister.gov CDM Page 11

12 Field Name SEXUAL_ORIENTATI ON_DESCRIPTION SQL Data Type varchar(50) Predefined Value Sets and Descriptive Text for Categorical See values above Description of sexual orientation Source GENDER_IDENTITY varchar(2) M=Man GENDER_IDENTITY_ DESCRIPTION F=Woman TM=Transgender Female-to-male TF=Transgender Maleto-female GQ=Genderqueer SE=Something else MU=Multiple gender categories DC=Decline to answer NI=No information UN=Unknown OT=Other Current gender identity. FederalRegi ster.gov varchar(50) See values above Description of gender identity HISPANIC nvarchar(2) Y=Yes N=No R=Refuse to answer NI=No information UN=Unknown OT=Other A person of Cuban, Mexican, Puerto Rican, South or Central American, or other Spanish culture or origin, regardless of race. Compatible with OMB Hispanic Ethnicity (Hispanic or Latino, Not Hispanic or Latino) cdc.gov/phi n/library/res CDM Page 12

13 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source HISPANIC_DESCRIPT ION varchar(50) See values above Text description of patient ethnicity. RACE nvarchar(2) 01=American Indian or Alaska Native 02=Asian 03=Black or African American 04=Native Hawaiian or Other Pacific Islander 05=White 06=Multiple race 07=Refuse to answer NI=No information UN=Unknown OT=Other RACE_DESCRIPTION varchar(50) See values above One race value per patient. Details of categorical definitions: American Indian or Alaska Native: A person having origins in any of the original peoples of North and South America (including Central America), and who maintains tribal affiliation or community attachment. Asian: A person having origins in any of the original peoples of the Far East, Southeast Asia, or the Indian subcontinent including, for example, Cambodia, China, India, Japan, Korea, Malaysia, Pakistan, the Philippine Islands, Thailand, and Vietnam. Black or African American: A person having origins in any of the black racial groups of Africa. Native Hawaiian or Other Pacific Islander: A person having origins in any of the original peoples of Hawaii, Guam, Samoa, or other Pacific Islands. White: A person having origins in any of the original peoples of Europe, the Middle East, or North Africa. Description of race. Value set is based upon U.S. Office of Managem ent and Budget (OMB) standard, and is compatible with the 2010 U.S. Census v/topics/po pulation/ra ce/about.h tml CDM Page 13

14 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source BIOBANK_FLAG nvarchar(1) Y=Yes N=No Flag to indicate that one or more bio-banked specimens are stored and available for research use. Examples of biospecimens could include blood, urine, or tissue (e.g. skin cells, organ tissues). If biospecimens are available, mapping tables are locally maintained to map between the DEMOGRAPHIC record and the originating biobanking system(s). If no known biobanked specimens are available, this field is marked No. RAW_SEX nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_SEXUAL_ ORIENTATION nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_HISPANIC nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_GENDER_ IDENTITY nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_RACE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. CONFIDENTIAL_ PATIENT_YN varchar(10) Y=Yes N=No Flag to indicate if the patient type is confidential. PRIMARY_LANGUAG E CURRENT_FAMILY_SI ZE varchar(300). Field to indicate the patient s primary language, such as English, Spanish, Russian, Vietnamese, etc. int. Number of persons in family/household supported by the household income. CURRENT_ANNUAL_I NCOME numeric(30,2). Annual household income. CDM Page 14

15 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source CURRENT_FPL_PERC ENTAGE numeric(30,2). Current federal poverty level FPL percentage calculated based on the most recent family size/income patient information, and the corresponding U.S. poverty guidelines for the year when these data were last collected. Invalid FPL percentages are changed to unknown percentages (raw values replaced with nulls) when either the corresponding family size or annual income fields contain standard numeric values used to specify unknown, or implausible values according to the following rules: Family size must be a value between 1 and 15 Annual income must be a value between $0 and $999, Annual income not equal to $99, (OCHIN only rule) CURRENT_MIGRANT_ SEASONAL_STATUS CURRENT_HOMELES S_STATUS varchar(100) Y=Yes N=No NI=No information Current migrant/seasonal worker status. Federally qualified health centers funded under sections 330(e) Health Center Grantee, 330(g) Migrant Health Center of the PHS Act and FQHC look-alikes are required to collect this information and report it to the HRSA bureau of primary care in their annual UDS Uniform Data System table 4 report. This Information is collected at a more granular, as required for UDS, however for these are rolled into Y, N and NI categories according to the following mapping: Y: Migrant Seasonal Vineyard Camp N: Neither Not Migrant/Seasonal NI: Null varchar(100). Current Homeless Status CDM Page 15

16 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source CURRENT_PRIMARY_ PAYOR_ID int. Raw provider identifier from source system. CURRENT_PRIMARY_ PAYOR varchar(300). The name of the payer associated with the patient s primary coverage on the most recent encounter (if any). CURRENT_PRIMARY_ PAYOR_TYPE varchar(100) - Medicaid - Medicare - Uninsured - Private Insurance - Other Public Insurance - Grant/Public - Self pay (without discount) - Self pay (with discount) - Workers Compensation Insurance type associated with the current primary payer. CURRENT_PAYOR_T YPE_RESEARCH varchar(100). Primary payor categories are grouped and in some cases recoded into specific categories for research purposes. CURRENT_PAYOR_MI LITARY char(1) Y=Yes N=No Current Payor Military ADANCE VETERAN_STATUS varchar(100) Y=Yes N=No NI=No information UN=Unknown Patients who have who have been discharged from the uniformed services of the United States. Persons, who are still in the uniform services, including soldiers on leave and National Guard members not on active duty, are not considered Veterans. FQHC funded under section 330(e) of the PHS Act and FQHC look-alikes are required to collect this information and report it to the HRSA bureau of primary care in their annual UDS Uniform Data System table 4 report. CDM Page 16

17 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source CURRENT_STATE_OF _RESIDENCE varchar(100) FL OR CA NM WA.. etc. Standard two-character state abbreviation associated with the patient s last known address information. The vast majority of these correspond to U.S. states and territories, however a very small percentage of these correspond to foreign states and provinces. CURRENT_ZIP varchar(50). Patient current zip code. LAST_VISIT_PC_DEP ARTMENT_NAME LAST_VISIT_PC_DEP ARTMENT_ID varchar(100). Department name associated with the patient s last primary care encounter. This information is generally not natively available in the EHR(s), however it is commonly used for analysis purposes, thus this is determined using encounter level data. varchar(100). Source system department ID associated with the patient s last primary care encounter. This information is generally not natively available in the EHR(s), however it is commonly used for analysis purposes, thus the ID is determined using encounter level data. CURRENT_PCP_STAT US varchar(100) Assigned Unassigned NI=No information Indicates whether or not patients are currently assigned to a general primary care provider. CURRENT_PCP_PRO VIDERID nvarchar(36). Current PCP provider ID ADANCE CURRENT_PCP_DEP T_ID varchar(100). Default source system department ID associated with the provider listed as the patient s general primary care provider (if any). CDM Page 17

18 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source FIRST_MEDICAL_ENC _DATE FIRST_DENTAL_ENC_ DATE FIRST_MH_BH_ENC_ DATE Date. Date of first medical encounter. Date. Date of first dental encounter. Date. Date of first mental health/ behavioral health encounter. LAST_BMI numeric(10,2). Last BMI value. LAST_BMI_DATE Date. Last BMI date DIABETES_YN char(1) Y N Null Y: A diagnosis of diabetes is present in the active problem list. N: Patient has problem list diagnoses, but either diabetes is not present, or the problem list was flagged as reviewed/no problems within 12 months prior to the patient s last ambulatory visit AV. Null: No problem list diagnoses, or problem list review flag (no data to determine Y/N value). DIABETES_TYPE_1_YN char(1) Y N Null Same as above DIABETES_TYPE_2_YN char(1) DYSRHYTHMIA_YN char(1) HEP_GENERAL_YN char(1) HIP_PELVIS_FX_YN char(1) CHF_YN char(1) CDM Page 18

19 OTHER_MH_YN OTHER_CA_YN HYPERLIPIDEMIA_YN PROSTATE_CA_YN PROSTATIC_HYPERPLA SIA_YN MENTAL_DISABILITY_Y N OBESITY_YN ANEMIA_YN BREAST_CA_YN LIVER_YN CRC_YN CVD_YN RHEUMATOID_YN BILIARY_YN DEPRESS_YN CHD_YN char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) char(1) CDM Page 19

20 TB_YN DM_SECONDARY_YN CYST_FIBROSIS_YN PERIPH_VASC_YN CKD_YN char(1) char(1) char(1) char(1) char(1) ALZ_YN ASTHMA_YN HEARING_YN MIGRAINE_HEADACHE _YN char(1) char(1) char(1) char(1) DM_NEUROPATHY_YN char(1) PSYCHOSIS_YN char(1) DM_RETINOPATHY_YN char(1) SUB_ABUSE_YN LUNG_CA_YN HTN_YN PRESSURE_ULCER_YN char(1) char(1) char(1) char(1) CDM Page 20

21 PAIN_YN OSTEO_YN EPILEPSY_YN HIV_AIDS_YN char(1) char(1) char(1) char(1) NEUROMUSCULAR_YN char(1) THYROID_YN ADHD_YN ALCOHOL_YN COPD_YN ENDOMETRIALCA_YN SKIN_CA_YN char(1) char(1) char(1) char(1) char(1) char(1) MOBILITY_IMPAIR_YN char(1) LEUKLYMPHOMA_YN ULCER_GERD_YN VISION_YN ANXIETY_PTSD_YN char(1) char(1) char(1) char(1) CDM Page 21

22 TOBACCO_YN char(1) ALPHA1_YN char(1) SITES varchar(200). Site(s) provenance field for internal use by. CDM Page 22

23 3.2 Table: ENROLLMENT ENROLLMENT Domain Description: Enrollment is a concept that defines a period of time during which all medically-attended events are expected to be observed. This concept is often insurance-based, but other methods of defining enrollment are allowed. currently uses a -approved algorithm to calculate encounter-based enrollment periods for all patients in the CDM. Relational Integrity: The ENROLLMENT table contains one record per unique combination of PATID, ENR_START_DATE, and BASIS. Composite Primary Key: PATID, ENR_START_DATE, ENR_BASIS Foreign Key: ENROLLMENT.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) Constraints: PATID (required, not null) ENR_START_DATE (required, not null) ENR_BASIS (required, not null) PATID + ENR_START_DATE + ENR_BASIS (unique) Additional Notes: The ENROLLMENT table has a start/stop structure that contains records for continuous enrollment periods. This table is designed to identify periods during which a person is expected to have complete data capture. A break in enrollment or a change in the chart abstraction flag generates a new record. The ENROLLMENT table provides an important analytic basis for identifying periods during which medical care should be observed, for calculating person-time, and for inferring the meaning of unobserved care (i.e. if care is not observed, it likely did not happen). algorithmic encounter-based definition of enrollment: Due to the lack of insurance enrollment data for most patients, uses the following algorithmic to calculate encounter-based enrollment periods. a) Enrolled active patients are defined as those with at least one ambulatory visit AV within 3 years prior to the most recent harvest date. b) Only AV encounters which took place on or after 1/1/2012 are considered in the algorithm. c) All AV encounters in the ENCOUNTER table are considered, regardless of source. d) The first enrollment start date for each patient corresponds to their first AV encounter on or after 1/1/2012. e) Gaps between consecutive AV encounters greater than 3 years generate new enrollment periods. f) When a gap is identified, the end-date for the corresponding enrollment period corresponds to the date of the last AV encounter plus 3 years. CDM Page 23

24 Example assuming that the CDM is refreshed on 3/31/2015: Patients with AV encounters on 1/1/2012, who do not have any subsequent encounters after 1/1/2012, have one enrollment record with a START_DATE = '1/1/2015' and ENR_END_DATE = '1/1/2015', and are considered inactive. If at some point any of these patients are seen again for an AV encounter, for example on 4/15/2015, a new enrollment record with ENR_START_DATE = '4/15/2015' and ENR_END_DATE = Null will be added to this table, and will be once again considered currently enrolled patients. Note: Once patients are enrolled in the CDM (based on the definition of enrollment) their data are never removed from the CDM, even if at some point they are no longer considered currently enrolled. ENROLLMENT Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. SAS_ENR_START_DA TE int. SAS data value. Represents the number of days between January 1, 1960, and the enr_start_date. ENR_START_DATE Date. Date of the beginning of the enrollment period. If the exact date is unknown, use the first day of the month. For implementation of the CDM, a long span of longitudinal data is desirable; however, especially for historical data more than a decade old, the appropriate beginning date should be determined by the data partner s knowledge of the validity and usability of the data. SAS_ENR_END_DAT E int. SAS data value. Represents the number of days between January 1, 1960, and the enr_end_date. ENR_END_DATE Date. Date of the end of the enrollment period. If the exact date is unknown, use the last day of the month. CDM Page 24

25 Field Name SQL Data Type CHART varchar(1) Y=Yes N=No Predefined Value Sets and Descriptive Text for Categorical Fields ENR_BASIS varchar(1) I=Insurance G=Geography A=Algorithmic E=Encounter- based Chart abstraction flag is intended to answer the question, "Are you able to request (or review) charts for this person?" This flag does not address chart availability. Mark as "Yes" if there are no contractual or other restrictions between you and the individual (or sponsor) that would prohibit you from requesting any chart for this patient. Note: This field is most relevant for health insurers that can request charts from affiliated providers. This field allows exclusion of patients from studies that require chart review to validate exposures and/or outcomes. It identifies patients for whom charts are never available and for whom the chart can never be requested. When insurance information is not available but complete capture can be asserted some other way, please identify the basis on which complete capture is defined. Additional information on the approach identified will be required from each data partner. ENR_BASIS is a property of the time period defined. A patient can have multiple entries in the table. Details of categorical definitions: Insurance: The start and stop dates are based upon the concept of enrollment with health plan insurance Geography: An assertion of complete data capture between the start and end dates based upon geographic characteristics, such as regional isolation Algorithmic: An assertion of complete data capture between the start and end dates, based on a locally developed or applied algorithm, often using multiple criteria Encounter-based: The start and stop dates are populated from the earliest-observed encounter and latest-observed encounter. Source CDM Page 25

26 Field Name ENR_BASIS_DESCRI PTION SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source varchar(16) See values above Description value for the enr_basis category. SITEID varchar(20). Site provenance field for internal use by. CDM Page 26

27 3.3 Table: ENCOUNTER ENCOUNTER Domain Description: Encounters are interactions between patients and providers within the context of healthcare delivery. Relational Integrity: The ENCOUNTER table contains one record per unique encounter. Primary Key: ENCOUNTERID Foreign Key: ENCOUNTER.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) Field Constraints: ENCOUNTERID (unique, required, not null) PATID (required, not null) ADMIT_DATE (required, not null) ENC_TYPE (required, not null) Inclusion: All encounter data available for patients in the DEMOGRAPHIC table (see inclusion criteria for patients in the DEMOGRAPHIC table). Exclusion: Known test, voided and erroneous encounters (as defined in each source system). Additional Notes: Each record generally reflects a unique combination of PATID, ADMIT_DATE, PROVIDERID and ENC_TYPE. Each diagnosis and procedure recorded during the encounter have a separate record in the DIAGNOSIS and PROCEDURES tables. Visits to different providers on the same day, such as a physician appointment that leads to a hospitalization, are generally considered multiple encounters in the source system. Note: Although Expired is represented in both DISCHARGE_DISPOSITION and DISCHARGE_STATUS, this overlap represents the reality that both fields are captured in hospital data systems but there is variation in which field is best populated. CDM Page 27

28 Guidance on the Encounter Type classification: For the situation where an Emergency Department (ED) encounter leads to a hospital admission: o The optimal, preferred state is to have one record for the ED (ENC_TYPE=ED), and a separate record for the hospital admission o (ENC_TYPE=IP) o However, this separation does not always exist in source data records. If the source system combines the ED and IP basis into one concept, a permissible substitution is to use ENC_TYPE=EI o Separate ED and IP records are not merged together. Generally, a reimbursement basis will determine the source system classification, instead of physical location. For example, a patient may occupy a hospital bed during an observation that is not classified as an inpatient hospital stay. Please note that stand-alone urgent care facilities are usually not established as Emergency Departments. CDM Page 28

29 Encounter Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier. Used to link records across tables, including the ENCOUNTER, DIAGNOSIS, and PROCEDURES tables. Source RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. AGE_AT_ENCOUNTER_ DATE Int. Patient age at encounter date. SAS_ADMIT_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the admit date. ADMIT_DATE Date. Encounter or admission date. ADMIT_TIME varchar(5): Format as HH:MI using 24-hour clock and zero-padding for hour and minute. Encounter or admission time. Source of time format: ISO 8601 CDM Page 29

30 Field Name SAS_DISCHARGE_DAT E SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields int. SAS data value. Represents the number of days between January 1, 1960, and the discharge date. Source DISCHARGE_DATE Date. Populated for all Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) and EDto-Inpatient (EI) encounter types. Missing for ambulatory encounters (AV or OA) DISCHARGE_TIME varchar(5): Format as HH:MI using 24-hour clock and zero-padding for hour and minute. Discharge time Source of time format: ISO 8601 PROVIDERID nvarchar(36). Provider ID for the provider who is most responsible for the encounter. As with PATID, the provider ID is a pseudo-identifier with a consistent crosswalk to the real identifier. RAW_PROVIDERID nvarchar(400). Raw provider level identifier from the source system. PROVIDER_TYPE varchar(200). Provider type description. FACILITY_LOCATION varchar(3) Geographic location (3 digit zip code) CDM Page 30

31 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields ENC_TYPE char(2) AV=Ambulatory Visit ED=Emergency Department EI=Emergency Department Admit to Inpatient Hospital Stay (permissible substitution) IP=Inpatient Hospital Stay IS=Non-Acute Institutional Stay OA=Other Ambulatory Visit NI=No information UN=Unknown OT=Other Ambulatory Visit: Includes visits at outpatient clinics, physician offices, same day/ambulatory surgery centers, urgent care facilities, and other same-day ambulatory hospital encounters, but excludes emergency department encounters. Emergency Department (ED): Includes ED encounters that become inpatient stays (in which case inpatient stays would be a separate encounter). Excludes urgent care facility visits. ED claims should be pulled before hospitalization claims to ensure that ED with subsequent admission won't be rolled up in the hospital event. Emergency Department Admit to Inpatient Hospital Stay: Permissible substitution for preferred state of separate ED and IP records. Only for use with data sources where the individual records for ED and IP cannot be distinguished Inpatient Hospital Stay: Includes all inpatient stays, including: same-day hospital discharges, hospital transfers, and acute hospital care where the discharge is after the admission date. Non-Acute Institutional Stay: Includes hospice, skilled nursing facility (SNF), rehab center, nursing home, residential, overnight non-hospital dialysis, and other non- hospital stays. Source Other Ambulatory Visit: Includes other non-overnight AV encounters such as hospice visits, home health visits, skilled nursing visits, other non-hospital visits, as well as telemedicine, telephone and consultations. May also include "lab only" visits (when a lab is ordered outside of a patient visit), "pharmacy only" (e.g., when a patient has a refill ordered without a face-to-face visit), "imaging only", etc. ENC_TYPE_DESCRIPTI ON varchar(50) See values above Description off encounter types. CDM Page 31

32 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical FACILITYID nvarchar(36). Arbitrary local facility ID that identifies the hospital or clinic. Used for chart abstraction and validation. Source FACILITYID is a pseudo-identifier with a consistent crosswalk to the true identifier. RAW_FACILITYID nvarchar(400). Raw facility id level identifier from the source system. FACILITY_NAME nvarchar(400). Name of the facility from the source system. FACILITY_TYPE varchar(50) NI Mental Health Early Childhood Program Administrative Case Management / Outreach Dental Services Primary Care Public Health Hospital Ancillary Services Vision Services Medical Specialty Social Work HEALTH_SYSTEM_NAM E Type of facility identified in the source system. varchar(200). Name of the health system as identified in the source system. HEALTH_SYSTEM_ID varchar(50). Raw health system level identifier from the Source system. CLINIC_SITE varchar(200). Clinic name. CDM Page 32

33 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Source FACILITY_STATE_ABBR varchar(5). Facility state abbreviation. FACILITY_ZIP Varchar(50). Facility zip code. DISCHARGE_DISPOSITI ON varchar(2) A=Discharged alive E=Expired NI=No information UN=Unknown OT=Other Populated for Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) and ED-to-Inpatient (EI) encounter types. Missing for ambulatory visit (AV or OA) encounter types. DISCHARGE_DISPOSITI ON_DESCRIPTION Varchar(16) See values above Description for the discharge disposition values. DISCHARGE_STATUS varchar(2) AF=Adult Foster Populated for Inpatient Hospital Stay (IP) and Non-Acute Home Institutional Stay (IS) encounter types. AL=Assisted Living Facility May be populated for Emergency Department (ED) and AM=Against Medical ED-to-Inpatient (EI) encounter types. Advice AW=Absent without Missing for ambulatory visit (AV or OA) encounter types. leave EX=Expired HH=Home Health HO=Home / Self Care HS=Hospice IP=Other Acute Inpatient Hospital NH=Nursing Home (Includes ICF) RH=Rehabilitation Facility RS=Residential Facility SH=Still In Hospital CDM Page 33

34 Field Name DISCHARGE_STATUS_ DESCRIPTION SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source varchar(60) See values above Description for the discharge status. DRG varchar(3). 3-digit Diagnosis Related Group (DRG). Populated for IP and IS encounter types. May be populated for Emergency Department (ED) and ED-to-Inpatient (EI) encounter types. Missing for AV or OA encounters. Codes less than 100 are padded with leading zeroes. The DRG is used for reimbursement for inpatient encounters. It is a Medicare requirement that combines diagnoses into clinical concepts for billing. Frequently used in observational data analyses. DRG_TYPE varchar(2) 01=CMS-DRG (old system) 02=MS-DRG (current system) NI=No information UN=Unknown OT=Other DRG code version. MS-DRG (current system) began on 10/1/2007. Populated for IP and IS encounter types. May be populated for Emergency Department (ED) and ED-to- Inpatient (EI) encounter types. Missing for AV or OA encounters. DRG_TYPE_DESCRIPTI ON varchar(40) See values above Description of the DRG Type. CDM Page 34

35 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields ADMITTING_SOURCE varchar(2) AF=Adult Foster Home AL=Assisted Living Facility AV=Ambulator y Visit ED=Emergenc y Department HH=Home Health HO=Home / Self Care HS=Hospice IP=Other Acute Inpatient Hospital NH=Nursing Home (Includes ICF) RH=Rehabilitation Facility RS=Residential Facility SN=Skilled ADMITTING_SOURCE_ DESCRIPTION Populated for Inpatient Hospital Stay (IP) and Non-Acute Institutional Stay (IS) encounter types. May be populated for Emergency Department (ED) and ED-to-Inpatient (EI) encounter types. Missing for ambulatory visit (AV or OA) encounter types. Source Varchar(50) See values above Description of the admitting source value. RAW_ENC_TYPE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_DISCHARGE_DIS POSITION nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_DISCHARGE_STA TUS nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_DRG_TYPE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_ADMITTING_SOU RC E nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. CDM Page 35

36 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical FAMILY_SIZE int Number of persons in family/household supported by the household income at the time of the encounter. Source ANNUAL_INCOME numeric(30,2) Annual household income at the time of the encounter. FPL_PERCENTAGE numeric(30,2). Federal poverty level FPL percentage calculated based on the most recent family size/income patient information available at the time of the encounter, and the corresponding U.S. poverty guidelines for the year when these data were collected. Invalid FPL percentages are changed to unknown percentages (raw values replaced with nulls) when either the corresponding family size or annual income fields contain standard numeric values used to specify unknown, or implausible values according to the following rules: Family size must be a value between 1 and 15 Annual income must be a value between $0 and $999, Annual income not equal to $99, (OCHIN only rule) CDM Page 36

37 Field Name MIGRANT_SEASONAL_ STATUS SQL Data Type varchar(100) Predefined Value Sets and Descriptive Text for Categorical Fields Y=Yes N=No NI=No information Migrant/seasonal worker status at the time of the encounter. Federally qualified health centers funded under sections 330(e) Health Center Grantee, 330(g) Migrant Health Center of the PHS Act and FQHC look-alikes are required to collect this information and report it to the HRSA bureau of primary care in their annual UDS Uniform Data System table 4 report. This Information is collected at a more granular, as required for UDS, however for these are rolled into Y, N and NI categories according to the following mapping: Y: Migrant Seasonal Vineyard Camp N: Neither Not Migrant/Seasonal NI: Null Source CDM Page 37

38 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical HOMELESS_STATUS varchar(100) Y=Yes N=No NI=No information Source Homeless status at the time of the encounter. Federally qualified health centers funded under sections 330(e) Health Center Grantee, 330(h) Health Care for the Homeless of the PHS Act and FQHC look-alikes are required to collect this information and report it to the HRSA bureau of primary care in their annual UDS Uniform Data System table 4 report. This Information is collected at a more granular, as required for UDS, however for these are rolled into Y, N and NI categories according to the following mapping: Y: Living in Shelter Doubling up Transitional Housing Living with Others Street, Camp or Bridge Homeless Unknown Shelter N: Not Homeless At Risk for Homeless Currently not Homeless, was in last 12 months NI: Null PRIMARY_PAYOR_ID numeric(18,0). Raw primary payor level identifier from the source system. PRIMARY_PAYOR varchar(300). The name of the payer associated with the patient s primary coverage at the time of the encounter. CDM Page 38

39 Field Name PRIMARY_PAYOR_TYP E PAYOR_TYPE_RESEAR CH SQL Data Type varchar(100) Predefined Value Sets and Descriptive Text for Categorical Fields - Medicaid - Medicare - Uninsured - Private Insurance - Other Public Insurance - Grant/Public - Self pay (without discount) - Self pay (with discount) - Workers Compensation Insurance type associated with the primary payer for the encounter. varchar(100). Primary payor categories are grouped and in some cases recoded into specific categories for research purposes. PAYOR_MILITARY char(1) Y=Yes N=No Payor Military LEVEL_OF_SERVICE varchar(50). The procedure code for the encounter's primary level of service. For medical face-to-face encounters this field typically contains the 5-digit CPT evaluation and management code that describes the level of care for the encounter, for example Office or Other Outpatient Visit for Established Patient CHARLSON_SCORE Int. Charlson comorbidity score at the encounter level. Calculated based on Problem List data. Patients may have a Charlson_Score of NULL if they do not have records in the Problem list table (they may however have dx records in the Diagnosis table). Source ADANCE Charlson_Score are currently available for OCHIN patients only. SITEID varchar(20). Site provenance field for internal use by. CDM Page 39

40 3.4 Table: DIAGNOSIS DIAGNOSIS Domain Description: Diagnosis codes indicate the results of diagnostic processes and medical coding within healthcare delivery. Relational Integrity: The DIAGNOSIS table contains one record per DIAGNOISID. Primary Key: DIAGNOSISID Foreign Keys: DIAGNOSIS.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) DIAGNOSIS.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (one-to-many relationship) Constraints: DIAGNOSISID (unique, required, not null) PATID (required, not null) ENCOUNTERID (required, not null) DX (required, not null) DX_TYPE (required, not null) DX_SOURCE (required, not null) Additional Notes: This table captures all uniquely recorded diagnoses for all encounters. Diagnoses from problem lists and medical history are captured in the separate CONDITION table. If a patient has multiple diagnoses associated with one encounter, then there would be one record in this table for each diagnosis. ENCOUNTERID is not optional for DIAGNOSIS and PROCEDURES. The definitions of the DIAGNOSIS and PROCEDURES tables are dependent upon a healthcare context; therefore, the ENCOUNTER basis is necessary. Data in this table are expected to be from healthcare-mediated processes and reimbursement drivers. This can include both technical/facility billing and professional billing. We recognize that, in many cases, these diagnoses may only be related to the treatment of the patient during the specific encounter. For example, chronic conditions may not be pertinent to the treatment of a specific encounter, and would not be expected to be present. If a local ontology is used, but cannot be mapped to a standard ontology such as ICD-9-CM, DX_TYPE is populated as Other. CDM Page 40

41 DIAGNOSIS Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source DIAGNOSISID bigint. Arbitrary identifier for each unique record. This identifier is not persistent across data refreshes. PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier. Used to link across tables. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. ENC_TYPE varchar(2) AV=Ambulatory Visit Please note: This is a field replicated from the ED=Emergency Department ENCOUNTER table. See the ENCOUNTER table EI=Emergency Department Admit to Inpatient Hospital for definitions. Stay (permissible substitution) IP=Inpatient Hospital Stay IS=Non-Acute Institutional Stay OA=Other Ambulatory Visit NI=No information UN=Unknown OT=Other ENC_TYPE_DESCRIP TION Varchar(50) See values above Description of encounter types SAS_ADMIT_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the admit date. ADMIT_DATE Date. Please note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions. PROVIDERID nvarchar(36). Please note: This is a field replicated from the ENCOUNTER table. See the ENCOUNTER table for definitions. CDM Page 41

42 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RAW_PROVIDERID nvarchar(200). Raw encounter level identifier from the source system. DX nvarchar(18). Diagnosis code. Leading zeroes and different levels of decimal precision are permissible in this field. Please populate the exact textual value of this diagnosis code, but remove source-specific suffixes and prefixes. Other codes should be listed as recorded in the source data. DX_DESCRIPTION varchar(500). Clinical term for the diangosis DX_TYPE varchar(2) 09=ICD-9-CM 10=ICD-10-CM 11=ICD-11-CM SM=SNOMED CT NI=No information UN=Unknown OT=Other Diagnosis code type. Other code types will be added as new terminologies are more widely used. Please note: the Other category is meant to identify internal use ontologies and codes. DX_TYPE_DESCRIPTI ON varchar(14) See values above Description of Dx Type. ICD_RUBRIC varchar(4). In the context of the ICD hierarchy, a rubric denotes either a 3-character category or a 4-character subcategory. Examples of ICD-9 diabetes mellitus related codes - 250, ICD-9 essential hypertension related codes ICD-10 Type-2 diabetes mellitus E11 ICD-10 Pure hypercholesterolemia E78 ICD-CM ICD_RUBRIC_DESCRI PTION varchar(500). Description of the ICD rubric category CDM Page 42

43 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source DX_SOURCE varchar(2) AD=Admitting DI=Discharge FI=Final IN=Interim NI=No information UN=Unknown OT=Other Classification of diagnosis source. The context is to capture available diagnoses recorded during a specific encounter. Ambulatory encounters generally have a source of Final. DX_SOURCE_DESCRI PTION varchar(14) See values above Description of the xx Source. PDX varchar(2) P=Principal S=Secondary X=Unable to Classify NI=No information UN=Unknown OT=Other Principal discharge diagnosis flag. Relevant only on IP and IS encounters. For ED, AV, and OA encounter types, mark as X=Unable to Classify. (Billing systems do not require a primary diagnosis for ambulatory visits (e.g. professional services).) One principle diagnosis per encounter is expected, although in some instances more than one diagnosis may be flagged as principal. PDX_DESCRIPTION varchar(18) See values above Description of the principal discharge diagnosis (PDX). RAW_DX nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_DX_TYPE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_DX_SOURCE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_PDX nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. SITEID varchar(20). Site provenance field for internal use by. CDM Page 43

44 3.5 Table: PROCEDURES PROCEDURES Domain Description: Procedure codes indicate the discreet medical interventions and diagnostic testing, such as surgical procedures, administered within healthcare delivery. Relational Integrity: The PROCEDURES table contains one record per PROCEDURESID. Primary Key: PROCEDURESID Foreign Keys: PROCEDURES.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) PROCEDURES.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (one-to-many relationship) Constraints: PROCEDURESID (unique, required, not null) PATID (required, not null) ENCOUNTERID (required, not null) PX (required, not null) PX_TYPE (required, not null) Additional Notes: This table captures all uniquely recorded procedures for all encounters. If a patient has multiple procedures ordered during one encounter, then there would be one record in this table for each procedure. ENCOUNTERID is not optional for DIAGNOSIS and PROCEDURES. The definitions of the DIAGNOSIS and PROCEDURES tables are dependent upon a healthcare context; therefore, the ENCOUNTER basis is necessary. Healthcare mediated process and reimbursement driver. Can include both technical/facility billing and professional billing. If a local ontology is used, but cannot be mapped to a standard ontology such as ICD-9-CM, PX_TYPE is populated as Other. CDM Page 44

45 PROCEDURES Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PROCEDURESID bigint. Arbitrary identifier for each unique record. These identifiers are not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier. Used to link across tables. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. ENC_TYPE varchar(2) AV=Ambulatory Visit This is a field replicated from the ED=Emergency ENCOUNTER table. See ENCOUNTER table for Department EI=Emergency definitions. Department Admit to Inpatient Hospital Stay (permissible substitution) IP=Inpatient Hospital Stay IS=Non-Acute Institutional Stay OA=Other Ambulatory Visit NI=No information UN=Unknown OT=Other ENC_TYPE_DESCRIPTI ON varchar(50) See values above Description of the encounter type. SAS_ADMIT_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the admit date. CDM Page 45

46 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source ADMIT_DATE Date. This is a field replicated from the ENCOUNTER table. See ENCOUNTER table for definitions. PROVIDERID nvarchar(36). This is a field replicated from the ENCOUNTER table. See ENCOUNTER table for definitions. RAW_PROVIDERID nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. SAS_PX_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the Px date. PX_DATE Date. Date the procedure was performed. PX nvarchar(11). Procedure code. PX_TYPE varchar(2) 09=ICD-9-CM 10=ICD-10-PCS 11=ICD-11-PCS C2=CPT Category II C3=CPT Category III C4=CPT-4 (i.e., HCPCS Level I) H3=HCPCS Level III HC=HCPCS (i.e., HCPCS Level II) LC=LOINC ND=NDC RE=Revenue NI=No information UN=Unknown OT=Other Procedure code type. A number of code types are included for flexibility, but the basic requirement that the code refer to a medical procedure remains. Medications administered by clinicians can be captured in billing data and Electronic Health Records (EHRs) as HCPCS procedure codes. Administration (infusion) of chemotherapy is an example. Please note: The Other category is meant to identify internal use ontologies and codes. PX_TYPE_DESCRIPTION varchar(40) See values above Description of the procedure code type. CDM Page 46

47 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PX_SOURCE varchar(2) OD=Order BI=Billing CL=Claim NI=No information UN=Unknown OT=Other Source of the procedure information. Order and billing pertain to internal healthcare processes and data sources. Claim pertains to data from the bill fulfillment, generally data sources held by insurers and other health plans. PX_SOURCE_DESCRIPT ION varchar(20) See values above Description of the souce of the procedure information. RAW_PX varchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. For OCHIN Epic records this field contains the internal PROC_ID procedure master file identifier. RAW_PX_TYPE varchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. SITEID varchar(20). Site provenance field for internal use by. CDM Page 47

48 3.6 Table: VITAL VITAL Domain Description: Vital signs (such as height, weight, and blood pressure) directly measure an individual s current state of attributes. Relational Integrity: The VITAL table contains one record per VITALID. Primary Key: VITALID Foreign Keys: VITAL.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) VITAL.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (zero-to-many relationship) Constraints: VITALID (unique, required, not null) PATID (required, not null) MEASURE_DATE (required, not null) VITAL_SOURCE (required, not null) Additional notes: The VITAL table contains one record per result/entry. Multiple measurements may exist in source data (for example, 3 blood pressure readings on the same day); each measurement would be a separate record. This table should be populated with all available measures. This table includes both healthcare and non-healthcare settings. CDM Page 48

49 Figure 1. Example of populated VITAL table: The encounter basis is optional. Measurements on the same date are recorded in different records; however, it is permissible to consolidate into one record if none of the measures were repeated. In this example, no time was recorded for several of the measures. Although preferable to capture time, we recognize that some source data may not include time precision. More than one blood pressure reading was collected during this encounter on January 5. Note: Completely fake data example created de novo, not from existing data. VITAL Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields VITALID bigint. Arbitrary identifier for each unique VITAL record. Not persistent across refreshes. Source PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36) Arbitrary encounter-level identifier. This is an optional relationship; the ENCOUNTERID is only present if the vitals were measured as part of healthcare delivery captured by this data-mart. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. SAS_MEASURE_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the measure date. MEASURE_DATE Date. Date of vitals measure. CDM Page 49

50 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source MEASURE_TIME varchar(5): HH:MI format using 24-hour clock and zero-padding for hour and minute Time of vitals measure. VITAL_SOURCE varchar(2) PR=Patient-reported PD=Patient device direct feed HC=Healthcare delivery setting HD=Healthcare device direct feed NI=No information UN=Unknown OT=Other The Patient-reported category can include reporting by patient s family or guardian. If unknown whether data are received directly from a device feed, use the more general context (such as patient-reported or healthcare delivery setting). VITAL_SOURCE_DESC RIPTION varchar(40) See values above Description of the vital source category values. HT numeric(10,2). Height (in inches) measured by standing. Only populated if measure was taken on this date. If missing, this value is null. WT numeric(10,2). Weight (in pounds). Only populated if measure was taken on this date. If missing, this value is null. DIASTOLIC numeric(4,0). Diastolic blood pressure (in mmhg). Only populated if measure was taken on this date. If missing, this value is null. SYSTOLIC numeric(4,0). Systolic blood pressure (in mmhg). Only populated if measure was taken on this date. If missing, this value is null. Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source CDM Page 50

51 ORIGINAL_BMI numeric(10,2). BMI as calculated in the source system. Original Not calculated BMI. This field reflects the originating source system calculations, if height and weight are not stored in the source system. BP_POSITION varchar(2) 01=Sitting 02=Standing 03=Supine NI=No information UN=Unknown OT=Other BP_POSITION_DESCRI PTION Position for orthostatic blood pressure. This value is null if blood pressure was not measured. varchar(14) See values above Description of the BP position for orthostatic blood pressure. SMOKING varchar(2) 01=Current every day smoker 02=Current some day smoker 03=Former smoker 04=Never smoker 05=Smoker, current status unknown 06=Unknown if ever smoked 07=Heavy tobacco smoker 08=Light tobacco smoker NI=No information UN=Unknown OT=Other Indicator for any form of tobacco that is smoked. Per Meaningful Use guidance, smoking status includes any form of tobacco that is smoked, but not all tobacco use. Light smoker is interpreted to mean less than 10 cigarettes per day, or an equivalent (but less concretely defined) quantity of cigar or pipe smoke. Heavy smoker is interpreted to mean greater than 10 cigarettes per day or an equivalent (but less concretely defined) quantity of cigar or pipe smoke. we understand that a current every day smoker or current some day smoker is an individual who has smoked at least 100 cigarettes during his/her lifetime and still regularly smokes every day or periodically, yet consistently; a former smoker would be an individual who has smoked at least 100 cigarettes during his/her lifetime but does not currently smoke; and a never smoker would be an individual who has not smoked 100 or more cigarettes during his/her lifetime. certification/2014-edition-draft-test-procedures/ a-11- smoking-status-2014-test-procedure-draft-v1.0.pdf [retrieved May 11, 2015] Meaningful Use Core Measures 9 of 13, Stage 1 (2014 definition) gov/regulations -and- Guidance/Legisl ation/ehrincent iveprograms/do wnloads/9_reco rd_smoking_sta tus.pdf [retrieved January 11, 2015] Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source CDM Page 51

52 SMOKING_DESCRIPTIO N varchar(50) See values above Smoking status description. TOBACCO varchar(2) 01=Current user 02=Never 03=Quit/former user 04=Passive or environmental exposure 06=Not asked NI=No information UN=Unknown OT=Other Indicator for any form of tobacco. TOBACCO_DESCRIPTI ON varchar(100) See values above Description of tobacco status. TOBACCO_TYPE varchar(2) 01=Smoked tobacco only 02=Non-smoked tobacco only 03=Use of both smoked and non-smoked tobacco products 04=None 05=Use of smoked tobacco but no information about non-smoked tobacco use NI=No information UN=Unknown OT=Other TOBACCO_TYPE_DESC RIPTION Type(s) of tobacco used. varchar(100) See values above Tobacco type description. RAW_HT nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM. Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RAW_WT nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM. CDM Page 52

53 RAW_BP_POSITION nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM value set. RAW_SYSTOLIC nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM. RAW_DIASTOLIC nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM. RAW_SMOKING nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM value set. RAW_TOBACCO nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM value set. RAW_TOBACCO_TYPE nvarchar(400). Optional field for originating value of field, prior to formatting into the CDM value set. SITEID varchar(20). Site provenance field for internal use by. CDM Page 53

54 3.7 Table: DISPENSING DISPENSING Domain Description: Outpatient pharmacy dispensing, such as prescriptions filled through a neighborhood pharmacy with a claim paid by an insurer. Outpatient dispensing is not commonly captured within healthcare systems. Relational Integrity (guidance added in v3.0): The DISPENSING table contains one record per DISPENSINGID. Primary Key: DISPENSINGID Foreign Keys: DISPENSING.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) DISPENSING.PRESCRIBINGID is a foreign key to PRESCRIBING.PRESCRIBINGID (zero-to-many relationship) Constraints: DISPENSINGID (unique, required, not null) PATID (required, not null) DISPENSE_DATE (required, not null) NDC (required, not null) Additional notes: Each record represents an outpatient pharmacy dispensing. This domain is commonly available in claims data, but may not be available in many EHR data sources. Medications administered in outpatient settings, such as infusions given in medical practices, would be expected to be present in the PROCEDURES table. Medications administered in inpatient settings may be captured in the PROCEDURES table if that level of detail is available in the source data. Dispensing is different from medication orders, prescribing, administration, and medication reconciliation of the active medication list. Rollback transactions and other adjustments that are indicative of a dispensing being canceled or not picked up by the member should be processed before populating this table. This may be handled differently by data partners and may be affected by billing cycles. In the uncommon situation where one NDC is dispensed more than once for a given patient on a given day, it is acceptable to aggregate the days supply and number of units. CDM Page 54

55 DISPENSING Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source DISPENSINGID bigint. Arbitrary identifier for each unique record. Not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. PRESCRIBINGID bigint. This is an optional relationship to the PRESCRIBING table, and is generally not available. One prescribing order may generate multiple dispensing records. SAS_DISPENSE_DAT E int. SAS data value. Represents the number of days between January 1, 1960, and the dispense date. DISPENSE_DATE Date. Dispensing date. NDC char(11). National Drug Code in the 11-digit, no-dash, HIPAA format. DISPENSE_SUP numeric(8,0). Days supply. Number of days that the medication supports based on the number of doses as reported by the pharmacist. This amount is typically found on the dispensing record. Integer values are expected. Important: This field is not calculated, if available, it reflects originating source system calculations. DISPENSE_AMT numeric(8,0). Number of units (pills, tablets, vials) dispensed. Net amount per NDC per dispensing. This amount is typically found on the dispensing record. Positive values are expected. This field is not calculated, if available, it reflects originating source system calculations. RAW_NDC nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM. SITEID varchar(20). Site provenance field for internal use by. CDM Page 55

56 3.8 Table: LAB_RESULT_CM LAB_RESULT_CM Domain Description: Laboratory result Common Measures (CM) use specific types of quantitative and qualitative measurements from blood and other body specimens. These standardized measures are defined in the same way across all networks. Relational Integrity: The LAB_RESULT_CM table contains one record per LAB_RESULT_CM_ID Primary Key: LAB_RESULT_CM_ID Foreign Keys: LAB_RESULT_CM.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) LAB_RESULT_CM.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (zero-to-many relationship) Constraints: LAB_RESULT_CM_ID (unique, required, not null) PATID (required, not null) RESULT_DATE (required, not null) Additional Notes: The LAB_RESULT_CM table contains one record per result/entry. Only records with actual lab results are included in this table. If the result suggests that the test was run (e.g., result is "borderline" or "inconclusive") it is included. But if the tests are not resulted for any reason (specimen not sufficient, patient did not show) these records should be excluded. The MSCDM concept of subcategory is not included in because of the subset of lab categories currently normalized. CDM Page 56

57 LAB_RESULT_CM Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields LAB_RESULT_CM_ID bigint. Arbitrary identifier for each unique LAB_RESULT_CM record. Not persistent across refreshes. Source PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier used to link across tables. This is an optional field, and is only populated if the lab was collected as part of a healthcare encounter captured in the ENCOUNTER table. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. LAB_NAME varchar(10) A1C=Hemoglobin A1c CK=Creatine kinase total CK_MB=Creatine kinase MB CK_MBI=Creatine kinase MB/creatine kinase total CREATININE=Creatinine HGB=Hemoglobin LDL=Low-density lipoprotein INR=International normalized ratio TROP_I=Troponin I cardiac TROP_T_QL=Troponin T cardiac (qualitative) TROP_T_QN=Troponin T cardiac (quantitative) Laboratory result common measure, a categorical identification for the type of test, which is harmonized across all contributing data partners. Please note that it is possible for more than one LOINC code, CPT code, and/or local code to be associated with one LAB_NAME. CDM Page 57

58 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source SPECIMEN_SOURCE varchar(10) BLOOD=blood CSF=cerebrospinal fluid PLASMA=plasma PPP=platelet poor plasma SERUM=serum SR_PLS=serum/plasma URINE=urine NI=No information UN=Unknown OT=Other Specimen source. SPECIMEN_SOURCE_D ESCRIPTION varchar(20) See values above Description of the specimen source. LAB_LOINC varchar(10). Logical Observation Identifiers, Names, and Codes (LOINC) from the Regenstrief Institute. Results with local versions of LOINC codes (e.g., LOINC candidate codes) should be included in the RAW_ table field, but the LOINC variable should be set to missing. Current LOINC codes are from 3-7 characters long but Regenstrief suggests a length of 10 for future growth. The last digit of the LOINC code is a check digit and is always preceded by a hyphen. All parts of the LOINC code, including the hyphen, are included. PRIORITY varchar(2) E=Expedite R=Routine S=Stat NI=No information UN=Unknown OT=Other Immediacy of test. The intent of this variable is to determine whether the test was obtained as part of routine care or as an emergent/urgent diagnostic test (designated as Stat or Expedite). PRIORITY_DESCRIPTIO N varchar(14) See values above Description of the priority catgory. RESULT_LOC varchar(2) L=Lab P=Point of Care NI=No information UN=Unknown OT=Other Location of the test result. Point of Care locations may include anticoagulation clinic, newborn nursery, finger stick in provider office, or home. The default value is L unless the result is Point of Care. CDM Page 58

59 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RESULT_LOC_DESCRIP TION varchar(14) See values above Description of the result location category. LAB_PX varchar(11). Optional variable for local and standard procedure codes, used to identify the originating order for the lab test. LAB_PX_DESCRIPTION varchar(254). Procedure code name. LAB_PX_TYPE varchar(2) 09=ICD-9 CM 10=ICD-10-PCS 11=ICD-11-PCS C2=CPT Category II C3=CPT Category III C4=CPT-4 (i.e., HCPCS Level I) H3=HCPCS Level III HC=HCPCS (i.e., HCPCS Level II) LC=LOINC ND=NDC RE=Revenue NI=No information UN=Unknown OT=Other Procedure code type, if applicable. LAB_PX_TYPE_DESCRI PTION varchar(40) See values above Description of the procedure code type. SAS_LAB_ORDER_DAT E int. SAS data value. Represents the number of days between January 1, 1960, and the lab order date. LAB_ORDER_DATE Date. Date test was ordered. SAS_SPECIMEN_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the specimen date. CDM Page 59

60 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source SPECIMEN_DATE Date. Date specimen was collected. SPECIMEN_TIME varchar(5): HH:MI format using 24-hour clock and zeropadding for hour and minute. Time specimen was collected. SAS_RESULT_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the result date. RESULT_DATE Date. Result date. RESULT_TIME varchar(5): HH:MI format using 24-hour clock and zeropadding for hour and minute RESULT_QUAL varchar(12) BORDERLINE POSITIVE NEGATIVE UNDETERMINED NI=No information UN=Unknown OT=Other. Result time. Standardized result for qualitative results. This variable contains NI for quantitative results. RESULT_NUM numeric(16,8). Standardized/converted result for quantitative results. This variable is null for qualitative results. RESULT_MODIFIER varchar(2) EQ=Equal GE=Greater than or equal to GT=Greater than LE=Less than or equal to LT=Less than TX=Text NI=No information UN=Unknown OT=Other Modifier for result values. Any symbols in the RAW_RESULT value are reflected in the RESULT_MODIFIER variable. For example, if the original source data value is "<=200" then RAW_RESULT=200 and RESULT_MODIFIER=LE. If the original source data value is text then RESULT_MODIFIER=TX. If the original source data value is a numeric value then RESULT_MODIFIER=EQ. CDM Page 60

61 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RESULT_MODIFIER_DE SCRIPTION varchar(24) See values above Description of the result modifier category. RESULT_UNIT varchar(11). Converted/standardized units for the result. Please see the standard abbreviations reference table 3 for additional details. NORM_RANGE_LOW varchar(10). Lower bound of the normal range assigned by the laboratory. Only contains the numeric value of the lower bound, symbols such as >, <, >= and <= are removed. For example, if the normal range for a test is >100 and <300, then this field contains "100". NORM_MODIFIER_LOW varchar(2) EQ=Equal GE=Greater than or equal to GT=Greater than NO=No lower limit NI=No information UN=Unknown OT=Other Modifier for NORM_RANGE_LOW values. For numeric results one of the following is true: 1) Both MODIFIER_LOW and MODIFIER_HIGH contain EQ (e.g. normal values fall in the range 3-10) 2) MODIFIER_LOW contains GT or GE and MODIFIER_HIGH contains NO (e.g. normal values are >3 with no upper boundary) 3) MODIFIER_HIGH contains LT or LE and MODIFIER_LOW contains NO (e.g. normal values are <=10 with no lower boundary) NORM_RANGE_HIGH varchar(10). Upper bound of the normal range assigned by the laboratory. Only contains the numeric value of the upper bound, symbols such as >, <, >= and <= are removed. For example, if the normal range for a test is >100 and <300, then this field contains "300". CDM Page 61

62 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source NORM_MODIFIER_HIGH varchar(2) EQ=Equal LE=Less than or equal to LT=Less than NO=No higher limit NI=No information UN=Unknown OT=Other Modifier for NORM_RANGE_HIGH values. For numeric results one of the following is true: 1) Both MODIFIER_LOW and MODIFIER_HIGH contain EQ (e.g. normal values fall in the range 3-10) 2) MODIFIER_LOW contains GT or GE and MODIFIER_HIGH contains NO (e.g. normal values are >3 with no upper boundary) 3) MODIFIER_HIGH contains LT or LE and MODIFIER_LOW contains NO (e.g. normal values are <=10 with no lower boundary) ABN_IND varchar(2) AB=Abnormal AH=Abnormally high AL=Abnormally low CH=Critically high CL=Critically low CR=Critical IN=Inconclusive NL=Normal NI=No information UN=Unknown OT=Other Abnormal result indicator. This represents the original, unmodified value in the source data. ABN_IND_DESCRIPTION varchar(15) See values above Description of the abnormal result indicator category. RAW_LAB_NAME nvarchar(400). Local code related to an individual lab test. This variable will not be used in queries, but may be used internally by to associate a record with a particular LAB_NAME. CDM Page 62

63 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RAW_LAB_CODE nvarchar(400). Local code related to an individual lab test. This variable will not be used in queries, but may be used internally by to associate a record with a particular LAB_NAME. RAW_PANEL nvarchar(400). Local code related to a battery or panel of lab tests. This variable will not be used in queries, but may be used internally by to associate a record with a particular LAB_NAME. RAW_RESULT nvarchar(400). The original test result value as seen in the source data. Values may include a decimal point, a sign or text (e.g., POSITIVE, NEGATIVE, DETECTED). The symbols >, <, >=, <= are removed from the value and stored in the Modifier variable instead. RAW_UNIT nvarchar(400). Original units for the result in the source data. RAW_ORDER_DEPT nvarchar(400). Local code for ordering provider department. RAW_FACILITY_CODE nvarchar(400). Local facility code that identifies the hospital or clinic. Taken from facility claims. SITEID varchar(20). Site provenance field for internal use by. CDM Page 63

64 Reference Table 3: Laboratory Standard Abbreviations Unit Type Standard Abbreviation Comments Billion BIL Billion is often written as "10*9". Cells CELL Decigram DG Deciliter DL Gram G International Units IU Do not confuse "1U" (one unit) or "/U" (per unit) with "IU" (International units). Thousand K Thousand is often written as "10*3". Liter L Milligram MG Milli-international units MIU Milliliter ML Nanogram NG Nanogram per milliliter is equivalent to microgram per liter (i.e., NG/ML=UG/L). Nanoliter NL Percent PERCENT Ratio RATIO Units U Microgram UG Microgram is often written as "MCG". Cubic Millimeter UL One cubic millimeter of blood is equivalent to one microliter. Cubic millimeter is often written as "MM*3" or "CU MM". Microliter UL Do not confuse "UL" (microliter) with "U/L" (units per liter). NI UN OT No Information (the source value is null or blank) Unknown (the source value explicitly denotes an unknown value) Other (the source value cannot be mapped) CDM Page 64

65 3.9 Table: CONDITION CONDITION Domain Description: A condition represents a patient s diagnosed and self-reported health conditions and diseases. The patient s medical history and current state are both represented. Relational Integrity: The CONDITION table contains one record per CONDITIONID. Primary Key: CONDITIONID Foreign Keys: CONDITION.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) CONDITION.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (zero-to-many relationship) Constraints: CONDITIONID (unique, required, not null) PATID (required, not null) CONDITION (required, not null) CONDITION_TYPE (required, not null) CONDITION_SOURCE (required, not null) Additional Notes: This table includes both healthcare and non-healthcare settings. Rollback or voided transactions and other adjustments should be processed before populating this table CDM Page 65

66 CONDITION Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields CONDITIONID bigint. Arbitrary identifier for each unique record. Not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier used to link across tables. This is an optional field, and it is only populated if the item was collected as part of a healthcare encounter recorded in the ENCOUNTER table. If more than one encounter association is present, this field is populated with the ID of the encounter when the condition was first entered into the system. However, please note that many conditions may be recorded outside of an encounter context. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. SAS_REPORT_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the report date. Source REPORT_DATE Date. Date condition was noted, which may be the date when it was recorded by a provider or nurse, or the date on which the patient reported it. Please note that this date may not correspond to onset date. (informed by ESP model) CDM Page 66

67 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields SAS_RESOLVE_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the resolve date. Source RESOLVE_DATE Date. Date condition was resolved, if resolution of a transient condition has been achieved. A resolution date is not generally expected for chronic conditions, even if the condition is managed. SAS_ONSET_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the onset date. ONSET_DATE Date. Please note that onset date is a very precise concept. Only populated from sources where this date is precisely defined and could be different than REPORT_DAT. The REPORT_DATE concept is better fit for most sources. CONDITION_STATUS char(2) AC=Active RS=Resolved IN=Inactive NI=No information UN=Unknown OT=Other Condition status corresponding with REPORT_DATE. The value of IN=Inactive is used in situations where a condition is not resolved, but is not currently active (for example, psoriasis). (informed by ESP model) CONDITION_STATUS_D ESCRIPTION varchar(50) See values above Condition status description. CDM Page 67

68 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields CONDITION varchar(18). Condition code. Leading zeroes and different levels of decimal precision are permissible in this field. This field is populated with the exact textual value of the diagnosis code, but source-specific suffixes and prefixes are removed. Source (modeled upon DIAGNOSIS table) CONDITION_DESCRIPTI ON varcahr(500). Clinical term of the condition (modeled upon DIAGNOSIS table) CONDITION_TYPE char(2) 09=ICD-9-CM 10=ICD-10-CM 11=ICD-11-CM SM=SNOMED CT HP=Human Phenotype Ontology AG=Algorithmic NI=No information UN=Unknown OT=Other Condition code type. Please note: The Other category is meant to identify internal use ontologies and codes. (modeled upon DIAGNOSIS table) CONDITION_TYPE_DES CRIPTION varchar(50) See values above Description of the condition code type. ICD_RUBRIC varchar(4) In the context of the ICD hierarchy, a rubric denotes either a 3-character category or a 4- character subcategory. Examples of ICD-9 diabetes mellitus related codes - 250, ICD-9 essential hypertension related codes ICD-10 Type-2 diabetes mellitus E11 ICD-10 Pure hypercholesterolemia E78 ICD-CM - WHO CDM Page 68

69 Field Name ICD_RUBRIC_DESCRIP TION SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source varchar(500) ICD Rubric code name/description ICD-CM - WHO CONDITION_SOURCE char(2) PR=Patientreported medical history HC=Healthcar e problem list RG=Registry cohort PC=- CONDITION_SOURCE_ DESCRIPTION varchar(50) See values above Please note: The Patient-reported category can include reporting by a proxy, such as patient s family or guardian. Registry cohort refers to cohorts of patients flagged with a certain set of characteristics for management within a health system. Condition source description. (modeled upon VITAL table) RAW_CONDITION_STAT US nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_CONDITION nvarchar(400. Optional field for originating value of field, prior to mapping into the CDM value set. RAW_CONDITION_TYP E nvarchar(400. Optional field for originating value of field, prior to mapping into the CDM value set. RAW_CONDITION_SOU RCE nvarchar(400. Optional field for originating value of field, prior to mapping into the CDM value set. SITEID varchar(20). Site provenance field for internal use by. CDM Page 69

70 3.10 Table: PRO_CM PRO_CM Domain Description: Patient-reported outcome Common Measures are standardized measures that are defined in the same way across all networks. Each measure is recorded at the individual item level: an individual question/statement, paired with its standardized response options. Relational Integrity: The PRO_RESPONSE table contains one record per PRO_CM_ID. Primary Key: PRO_CM_ID Foreign Keys: PRO_CM.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) PRO_CM.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (zero-to-many relationship) Constraints: PRO_CM_ID (unique, required, not null) PATID (required, not null) PRO_ITEM (required, not null) PRO_DATE (required, not null) PRO_RESPONSE (required, not null) Additional Notes: This table supports the Common Measures established by the PRO Task Force. Please see the Table 4 Common Reference for information about these measures. CDM Page 70

71 PRO_CM Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PRO_CM_ID bigint. Arbitrary identifier for each unique record. Not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier for the patient for MSCDM whom the PRO response was captured. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier used to link across tables. This is an optional field, and it is populated only if the item was collected as part of a healthcare encounter recorded in the ENCOUNTER table. (modeled upon VITAL table) RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. PRO_ITEM char(10) PN_0001=GLOBAL01 PN_0002=GLOBAL02 PN_0003=GLOBAL06 PN_0004=PFA53 PN_0005=EDDEP29 PN_0006=HI7 PN_0007=SLEEP20 PN_0008=SRPPER11_CA PS PN_0009=PAININ9 PN_0010=3793R1 PN_0011=28676R1 PN_0012=EOS_P_011 PN_0013=PEDSGLOBAL2 PN_0014=PEDSGLOBAL5 PN_0015=PEDSGLOBAL6 PN_0016=GLOBAL03 PN_0017=GLOBAL04 PN_0018=EDANX53 PN_0019=SAMHSA PN_0020=CAHPS 4.0 PN_0021=PA070 or internal identifier for the specific Common Measure item. Please see Table 4 Common Reference for more details, and list of custom specific identifiers. CDM Page 71

72 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PRO_ITEM_QUESTION varchar(203). PRO item question. PRO_LOINC char(10). LOINC code for item context and stem. Please see Table 4 Common Reference for known LOINC codes for each common measure. Logical Observation Identifiers, Names, and Codes (LOINC) from the Regenstrief Institute. Results with local versions of LOINC codes (e.g., LOINC candidate codes) are included in the RAW_ table field, but the PRO_LOINC variable are set to missing. Current LOINC codes are 3-7 characters long but Regenstrief suggests a length of 10 for future growth. The last digit of the LOINC code is a check digit and is always preceded by a hyphen. All parts of the LOINC code, including the hyphen, are included. LOINC code are not padded with leading zeros. SAS_PRO_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the pro date. (modeled on LAB_RES ULT_CM table) PRO_DATE Date. The date of the response. PRO_TIME varchar(5): HH:MI format using 24-hour clock and zeropadding for hour and minute. The time of the response. Source of time format: ISO 8601 PRO_RESPONSE numeric(8,2). The numeric response recorded for the item. Please see Table 4. Common Measures reference, Value List column, for the list of numeric valid values for each item. CDM Page 72

73 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PRO_METHOD char(2) PA=Paper EC=Electronic PH=Telephonic IV=Telephonic with interactive voice response (IVR) technology NI=No information UN=Unknown OT=Other Method of administration. Electronic includes responses captured via a personal or tablet computer, at web kiosks, or via a smartphone. PRO_METHOD_DESCRI PTION varchar(100) See values above Description of the PRO method of administration. PRO_MODE char(2) SF=Self without assistance SA= Self with assistance PR=Proxy without assistance PA=Proxy with assistance NI=No information UN=Unknown OT=Other PRO_MODE_DESCRIPTI ON The person who responded on behalf of the patient for whom the response was captured. A proxy report is a measurement based on a report by someone other than the patient reporting as if he or she is the patient, such as a parent responding for a child, or a caregiver responding for an individual unable to report for themselves. Assistance excludes providing interpretation of the patient s response. varchar(100) See values above Description of the PRO mode. PRO_CAT char(2) Y=Yes N=No NI=No information UN=Unknown OT=Other Indicates whether Computer Adaptive Testing (CAT) was used to administer the survey or instrument that the item was part of. May apply to electronic (EC) and telephonic (PH or IV) modes. RAW_PRO_CODE nvarchar(400). Optional field for originating code, such as LOINC candidate codes that have not yet been adopted RAW_PRO_RESPONSE nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. SITEID varchar(20). Site provenance field for internal use by. CDM Page 73

74 Common Measures currently implemented and custom PRO measures are highlighted in yellow: Reference Table 4: PRO Common Measures This table is based upon the Final Report from the Patient-reported Outcomes (PRO) Common Measures Working Group (CMWG), October 25, Domain Item Text Value Set Item Code Item Bank PRO LOINC # for Unique TF Item Recommend Bank / Identifier ation Domain General Health Quality of Life Physical Function (alternate) Physical Function In general, would you say your health is In general, would you say your quality of life is To what extent are you able to carry out your everyday physical activities such as walking, climbing stairs, carrying groceries, or moving a chair? Are you able to run errands and shop? 5=Excellent 4=Very good 3=Good 2=Fair 1=Poor 5=Excellent 4=Very good 3=Good 2=Fair 1=Poor 5=Completely 4=Mostly 3=Moderately 2=A little 1=Not at all 5=Without any difficulty 4=With a little difficulty 3=With some difficulty 2=With much difficulty 1=Unable to do PN_0001 PN_0002 PN_0003 GLOBAL 01 GLOBAL 02 GLOBAL 06 PROMIS Global PROMIS Global PROMIS Global PN_0004 PFA53 PROMIS Physical Function Core Item (Adult and Pediatric) Core Item (Adult and Pediatric) Core Adult Item Core Adult Item Parent panel: Panel: Parent panel: Panel: Parent panel: Panel: Parent panel: Panel: LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Not available Depression In the past 7 days I 1=Never PN_0005 EDDEP29 PROMIS Core Adult Parent panel: felt depressed 2=Rarely Emotional Item =Sometimes Distress- Panel: 4=Often Depression CDM 5=Always Page 74

75 Domain Item Text Value Set Unique Identifier Fatigue During the past 7 days I feel fatigued Sleep Disturbance Social Roles & Activities Pain Interference Pain Interference In the past 7 days I had a problem with my sleep I have trouble doing all of my regular leisure activities with others In the past 7 days How much did pain interfere with your day to day activities? In the past 7 days I had trouble sleeping when I had pain 1=Not at all 2=A little bit 3=Somewhat 4=Quite a bit 5=Very much 1=Not at all 2=A little bit 3=Somewhat 4=Quite a bit 5=Very much 5=Never 4=Rarely 3=Sometimes 2=Usually 1=Always 1=Not at all 2=A little bit 3=Somewhat 4=Quite a bit 5=Very much 0=Never 1=Almost Never 2=Sometimes 3=Often 4=Almost Always Item Code Item Bank PRO TF Recommend ation PN_0006 HI7 PROMIS Fatigue PN_0007 SLEEP20 PROMIS Sleep Disturbance PN_0008 SRPPER11 _CaPS PROMIS Social Role Participation PN_0009 PAININ9 PROMIS Pain Interference PN_ R1 PROMIS Peds Pain Interference Core Adult Item LOINC # for Item Bank / Domain Parent panel: Panel: Core Adult Item Parent panel: Panel: Core Adult Item Parent panel: Panel: Core Adult Item Parent panel: Panel: Core Pediatric Item Parent panel: Panel: LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Fatigue In the past 7 days I got tired easily 0=Never 1=Almost Never 2=Sometimes 3=Often 4=Almost Always PN_ R1 PROMIS Peds Fatigue Core Pediatric Item Parent panel: Panel: Stress In the past 7 days I felt stressed 1=Never 2=Almost Never 3=Sometimes 4=Often 5=Almost Always PN_0012 EOS_P_01 1 PROMIS Peds - Stress Core Pediatric Item Parent panel: Panel: CDM Page 75

76 Domain Item Text Value Set Unique Identifier Item Code Item Bank PRO TF Recommend ation LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Depression How often do you feel really sad 1=Never 2=Rarely 3=Sometimes 4=Often 5=Always PN_0013 PEDGLO BAL2 PROMIS Peds - Global Core Pediatric Item Parent panel: Panel: Peer Relationships How often do you have fun with friends 1=Never 2=Rarely 3=Sometimes 4=Often 5=Always PN_0014 PEDGLO BAL5 PROMIS Peds - Global Core Pediatric Item Parent panel: Panel: Family Relationship s How often do your parents listen to your ideas? 1=Never 2=Rarely 3=Sometimes 4=Often 5=Always PN_0015 PEDGLO BAL6 PROMIS Peds - Global Core Pediatric Item Parent panel: Panel: Global Physical Health In general, how would you rate your physical health? 5=Excellent 4=Very good 3=Good 2=Fair 1=Poor PN_0016 GLOBAL 03 PROMIS Global Recommended Item (Adult and Pediatric) Parent panel: Panel: Global Mental Health In general, how would you rate your mental health including your mood and your ability to think? 5=Excellent 4=Very good 3=Good 2=Fair 1=Poor PN_0017 GLOBAL 04 PROMIS Global Recommended Item (Adult and Pediatric) Parent panel: Panel: Anxiety In the past 7 days I felt uneasy 1=Never 2=Rarely 3=Sometimes 4=Often 5=Always PN_0018 EDANX53 PROMIS Emotional Distress- Anxiety Recommended Item (Adult and Pediatric) Parent panel: Panel: CDM Page 76

77 Domain Item Text Value Set Unique Identifier Medication Adherence In the past 7 days People often miss a dose of their medicines from time to time. How many days in the past week did you miss taking one or more of your medications? Range between 0-7 Item Code Item Bank PRO TF Recommend ation PN_0019 SAMHSA Core Psychosocial & Behavioral Recommended Item (Adult) LOINC # for Item Bank / Domain Parent panel: Panel: LOINC # SNOMED for Item SCTID for Context + domain Stem (2010) (2014) Experience of Care (Evaluation of Care/"Treatm ent Satisfaction") Past 12 months Using any number from 0 to 10, where 0 is the worst health care possible and 10 is the best health care possible, what number would you use to rate all your health care in the last 12 months? Range between 0-10 PN_0020 CAHPS 4.0 CAHPS Experience of Care Recommended Item (Adult and Pediatric) Parent panel: Panel: Not available Life Satisfaction I have a good life 1=Strongly disagree 2=Disagree 3=Neither agree nor disagree 4=Agree 5=Strongly agree PN_0021 PA070 Toolbox Psychologica l Well-Being Life Satisfaction Recommended Item (Adult and Pediatric) Parent panel: Panel: Depression Have you had little interest or pleasure doing things in the past 2 weeks? 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day ADV_0001 PHQ CDM Page 77

78 Domain Item Text Value Set Unique Identifier Depression Depression Depression Depression Depression Have you been feeling down, depressed or hopeless in the past 2 weeks? Have you had trouble falling or staying asleep, or sleeping too much in the past 2 weeks? Have you been feeling tired or had little energy in the past 2 weeks? Have you had a poor appetite or overeating in the past 2 weeks? Have you been feeling bad about yourself - or that you are a failure or have let yourself or your family down in the past 2 weeks? 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day Item Code Item Bank PRO TF Recommend ation LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) ADV_0002 PHQ ADV_0003 PHQ ADV_0004 PHQ ADV_0005 PHQ ADV_0006 PHQ Depression Have you had trouble 1=Not at all ADV_0007 PHQ concentrating on 2=Several days things, such as 3=More than half reading the the days newspaper or 4=Nearly every watching TV in the day past 2 weeks? CDM Page 78 SNOMED SCTID for domain (2010)

79 Domain Item Text Value Set Unique Identifier Depression Have you been moving or speaking so slowly that other people could have noticed? Or the opposite - being so fidgety & restless that you have been moving around a lot more than usual in the past 2 weeks? 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day Item Code Item Bank PRO TF Recommend ation LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) ADV_0008 PHQ SNOMED SCTID for domain (2010) Depression Depression Have you had thoughts that you would be better off dead, or of hurting yourself in the past 2 weeks? If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Depression During the past 2 weeks, have you been feeling down, depressed or hopeless? Yes/No Depression During the past 2 weeks, have you been bothered by little interest or pleasure in doing things? Yes/No 1=Not at all 2=Several days 3=More than half the days 4=Nearly every day 1=Not difficult at all 2=Somewhat difficult 3=Very difficult 4=Extremely difficult NI=No Response Yes No No Response Yes No No Response ADV_0009 PHQ ADV_0011 PHQ ADV_0012 PHQ ADV_0013 PHQ CDM Page 79

80 Domain Item Text Value Set Unique Identifier Depression Patient Health Questionnaire PHQ- Total Score (0-27) Item Code Item Bank PRO TF Recommend ation LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014). ADV 0014 PHQ SNOMED SCTID for domain (2010) Alcohol How often do you have a drink containing alcohol? 1= Never 2= Monthly or less 3= 2-4 times a month 4= 2-3 times a week 5= 4 or more times a week 6= No Response ADV 0015 AUDIT-C Alcohol How many drinks containing alcohol do you have on a typical day when you are drinking? 1=1 or 2 2=3 or 4 3=5 or 6 4=7-9 5=10 or more 6=No Response ADV 0016 AUDIT-C Alcohol How often do you have 4 or more drinks on one occasion? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6= No Response ADV 0017 AUDIT-C Alcohol How often during the last year have you found that you were not able to stop drinking once you had started? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6-No Response ADV 0018 AUDIT CDM Page 80

81 Domain Item Text Value Set Unique Identifier Item Code Item Bank PRO TF Recommendat ion LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Alcohol How often during the last year have you failed to do what was normally expected from you because of drinking? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6-No Response ADV 0019 AUDIT Alcohol How often during the last year have you needed a first drink in the morning to get yourself going after a heavy drinking session? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6-No Response ADV 0020 AUDIT Alcohol How often during the last year have you had a feeling of guilt or remorse after drinking? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6-No Response ADV 0021 AUDIT Alcohol How often during the last year have you been unable to remember what happened the night before because of your drinking? 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6-No Response ADV 0022 AUDIT CDM Page 81

82 Domain Item Text Value Set Unique Identifier Item Code Item Bank PRO TF Recommendat ion LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Alcohol Have you or someone else been injured as a result of your drinking? 1=No 2=Yes, but not in the last year 3=Yes, in the last year 4=No Response ADV 0023 AUDIT Alcohol Has a relative or friend or a doctor or another health worker been concerned about your drinking or suggested you cut down? 1=No 2=Yes, but not in the last year 3=Yes, in the last year 4=No Response ADV 0024 AUDIT Alcohol How often do you have 6 more drinks on one occasion? (Retired row) 1=Never 2=Less than monthly 3=Monthly 4=Weekly 5=Daily or almost daily 6=No Response ADV 0025 AUDIT-C Alcohol Alcohol Use Disorders Identification Test (AUDIT) - Total Score (0-40). ADV 0039 AUDIT CDM Page 82

83 Domain Item Text Value Set Unique Identifier Alcohol -? How many times in the past year have you had 5 or more drinks (men) or 4 or more drinks (women) in a day? 1=None 2=1 or more 3=No Response Item Code Item Bank PRO TF Recommendat ion LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) ADV 0026 SBIRT SNOMED SCTID for domain (2010) Alcohol -? How many times in the past year have you used a recreational drug or used a prescription drug for nonmedical reasons? 1=None 2=1 or more 3=No Response ADV 027 SBIRT Drug Have you used drugs other than those required for medical reasons? 1=No 2=Yes 3=No Response ADV 028 DAST Drug Do you abuse more than one drug at a time? 1=No 2=Yes 3=No Response ADV 029 DAST Drug Are you always able to stop using drugs when you want to? 1=No 2=Yes 3=No Response ADV 030 DAST-10 CDM Page 83

84 Domain Item Text Value Set Unique Identifier Drug Have you ever had blackouts or flashbacks as a result of drug use? 1=No 2=Yes 3=No Response Item Code Item Bank PRO TF Recommendat ion LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) ADV 031 DAST SNOMED SCTID for domain (2010) Drug Do you ever feel bad or guilty about your drug use? 1=No 2=Yes 3=No Response ADV 032 DAST Drug Does your spouse (or parents) ever complain about your involvement with drugs? 1=No 2=Yes 3=No Response ADV 033 DAST Drug Have you neglected your family because of your use of drugs? 1=No 2=Yes 3=No Response ADV 034 DAST Drug Have you engaged in illegal activities in order to obtain drugs? 1=No 2=Yes 3=No Response ADV 035 DAST CDM Page 84

85 Domain Item Text Value Set Unique Identifier Item Code Item Bank PRO TF Recommendat ion LOINC # for Item Bank / Domain LOINC # for Item Context + Stem (2014) SNOMED SCTID for domain (2010) Drug Have you ever experienced withdrawal symptoms (felt sick) when you stopped taking drugs? 1=No 2=Yes 3=No Response ADV 036 DAST Drug Have you had medical problems as a result of your drug use (e.g. memory loss, hepatitis, convulsions, bleeding)? 1=No 2=Yes 3=No Response ADV 0037 DAST Drug Are you unable to stop using drugs when you want to? 1=No 2=Yes 3=No Response ADV 0038 DAST Drug Drug Abuse Screening Test (DAST-10) Total Score (0-10). ADV 0040 DAST-10 CDM Page 85

86 3.11 Table: PRESCRIBING PRESCRIBING Domain Description: Provider orders for medication dispensing and/or administration. Relational Integrity: The PRESCRIBING table contains one record per PRESCRIBINGID. Primary Key: PRESCRIBINGID Foreign Keys: PRESCRIBING.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) PRESCRIBING.ENCOUNTERID is a foreign key to ENCOUNTER.ENCOUNTERID (zero-to-many relationship) Constraints: PRESCRIBINGID (unique, required, not null) PATID (required, not null) Additional Notes: The PRESCRIBING table contains one record per prescription. All prescribed medications are included, even if these cannot be mapped to RxNorm. Medication reconciliation / active med list records, such as patient reported medications, documented as historical medications or prescribed by external providers, are not included in the PRESCRIBING table and are currently not represented in the CDM. This domain will be reviewed and consider for potential inclusion in the CDM during phase II. CDM Page 86

87 PRESCRIBING Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PRESCRIBINGID bigint. Arbitrary identifier for each unique PRESCRIBING record. Not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier. This is an optional relationship; the ENCOUNTERID is present only if the prescribing activity is directly associated with an encounter represented in the ENCOUNTER table. RAW_ENCOUNTERID nvarchar(200). Raw encounter level identifier from the source system. RX_PROVIDERID nvarchar(36). Provider code for the provider who prescribed the medication. The provider code is a pseudoidentifier with a consistent crosswalk to the real identifier. RAW_RX_PROVIDERID nvarchar(400). Raw provider level identifier from the source system. SAS_RX_ORDER_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the rx order date. MSCDM MSCDM, based upon ENCOUNTER table RX_ORDER_DATE Date. Order date of the prescription by the provider. MSCDM RX_ORDER_TIME varchar(5): HH:MI format using 24-hour clock and zeropadding for hour and minute. Order time of the prescription by the provider. CDM Page 87

88 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source SAS_RX_START_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the rx start date. RX_START_DATE Date. Start date of order. This attribute may not be consistent with the date on which the patient actually begin taking the medication. SAS_RX_END_DATE int. SAS data value. Represents the number of days between January 1, 1960, and the rx end date. Based on ESP RX_END_DATE Date. End date of order (if available). Based on ESP RX_QUANTITY numeric(8,0). Quantity ordered. Based on OMOP and ESP RX_REFILLS numeric(8,0). Number of refills ordered (not including the Based on OMOP and original prescription). If no refills are ordered, the ESP value should be zero. RX_DAYS_SUPPLY numeric(8,0). Number of days supply ordered, as specified by the prescription. Based on OMOP RX_FREQUENCY char(2) 01=Every day 02=Two times a day (BID) 03=Three times a day (TID) 04=Four times a day (QID) 05=Every morning 06=Every afternoon 07=Before meals 08=After meals 09=As needed (PRN) NI=No information UN=Unknown OT=Other Specified frequency of medication. RX_FREQUENCY_DESC RIPTION varchar(50) See values above Description of the Rx frequency category. CDM Page 88

89 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RX_BASIS char(2) 01=Dispensing 02=Administration NI=No information UN=Unknown OT=Other Basis of the medication order RX_BASIS_DESCRIPTIO N varchar(40) See values above Description of the Rx basis category. RXNORM_CUI nvarchar(10). Where an RxNorm mapping exists for the source medication, this field contains the RxNorm concept identifier (CUI) at the highest possible specificity. If more than one option exists for mapping, the following ordered strategy based on level of specificity is used: 1)Semantic generic clinical drug 2)Semantic Branded clinical drug 3)Generic drug pack 4)Branded drug pack RX_DOSE_NUM numeric(4,0). RX_DOSE_UNIT nvarchar (11) RAW_RX_FREQUEN CY nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. RAW_RX_MED_NAM E nvarchar(400). Optional field for originating, full textual medication name from the source. RAW_RXNORM_CUI nvarchar(400). Optional field for originating value of field, prior to mapping into the CDM value set. OPIOID_ALL int. Flag for opioid medication (including opioid cough medication) OPIOID_COUGH Int. Flag for opioid cough medication only SITEID varchar(20). Site provenance field for internal use by. CDM Page 89

90 3.12 Table: PCORNET_TRIAL PCORNET_TRIAL Domain Description: Patients who are enrolled in clinical trials. Relational Integrity: The PCORNET_TRIAL table contains one record per unique combination of PATID, TRIALID, and PARTICIPANTID. Composite Primary Key: PATID, TRIALID, PARTICIPANTID Foreign Key: PCORNET_TRIAL.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many) Constraints: PATID (required, not null) TRIALID (required, not null) PARTICIPANTID (required, not null) PATID + TRIALID + PARTICIPANTID (unique) Additional Notes: This CDM table is currently not used by, and does not contain any records. This table is only used for clinical trials, not for observational studies One patient participating in multiple trials will have multiple records Each trial will define its parameters for enrollment o Patients who decline to participate in a trial or do not meet eligibility criteria should not be included in this table o Patients who enroll in a trial but later withdraw should be included in this table so that their withdraw state is appropriately recognized and any prior data are appropriate managed In most cases, trials will be expected to have a separate trial database that is separate from the CDM A trial may include (but is not limited to) both randomized and non-randomized studies o Randomization arms are not included in this table due to the issue of potentially unblinding the patient assignments. Randomization assignment will instead be present in the separate trial database. PATID is not generally appropriate for use as a PARTICIPANTID because it is not disambiguated across networks. CDM Page 90

91 The PCORNET_TRIAL table serves as a connector and filter for CDM data within the parameters of a given trial protocol: CDM Tables (within a specific CDRN Datamart) Associate the CDM domains specified in the trial protocol PCORNET_TRIAL Trial Database (eg, ADAPTABLE) PATID TRIALID Which patient? Which trial? Associate the study records PARTICIPANTID Which person? Work with CDM data in the correct timeframe TRIAL_ENROLL_DATE TRIAL_END_DATE TRIAL_WITHDRAW_DATE TRIAL_INVITE_CODE If used by trial May contain: Consent module Randomization assignment Study-specific data collection Study-specific schedule of assessments CDM Page 91

92 PCORNET_TRIAL Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. TRIALID varchar(20). Each TRIALID is assigned by the trial s coordinating center. PARTICIPANTID nvarchar(36). Arbitrary person-level identifier used to uniquely identify a participant in a trial. PARTICIPANTID is never repeated or reused for a specific clinical trial, and is generally assigned by trial-specific processes. It may be the same as a randomization ID. TRIAL_SITEID varchar(20). Each TRIAL_SITEID is assigned by the trial coordinating center. TRIAL_ENROLL_DATE Date. Date on which the participant enrolled in the trial (generally coincides with trial consent process). TRIAL_END_DATE Date Date on which the participant completes participation in the trial. TRIAL_WITHDRAW_DATE Date. If applicable, date on which the participant withdraws consent from the trial. TRIAL_INVITE_CODE varchar(20). Textual strings used to uniquely identify invitations sent to potential participants, and allows acceptances to be associated back to the originating source. MSCDM Where used, there should generally be a unique combination of PATID, TRIAL_NAME, and INVITE_CODE within each datamart. For example, this might include coenrollment ID strings for invites or verification codes for letter invites. CDM Page 92

93 3.13 Table: DEATH DEATH Domain Description: Reported mortality information for patients. Relational Integrity: The DEATH table contains one record per unique combination of PATID, DEATH_DATE, and DEATH_SOURCE. Composite Primary Key: PATID, DEATH_DATE, DEATH_SOURCE Foreign Key: DEATH.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) Constraints: PATID (required, not null) DEATH_DATE (required, not null) DEATH_SOURCE (required, not null) PATID + DEATH_DATE + DEATH_SOURCE (unique) Additional Notes: One patient may potentially have multiple records in this table because their death may be reported by different sources. DEATH_DATE is currently a required field in the CDM, and estimation of this date is currently under consideration but currently not allowed, because of this constraint, patients indicated as deceased in the source systems who do not have a death date documented are currently not included in this table. Deaths represented in the ENCOUNTER.DISCHARGE_DISPOSITION and ENCOUNTER.DISCHARGE_STATUS are generally also represented in this table. CDM Page 93

94 DEATH Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. MSCDM RAW_PATID nvarchar(36). Raw patient level identifier from the source system. SAS_DEATH_DATE Int. SAS data value. Represents the number of days between January 1, 1960, and the death date. DEATH_DATE Date Date of death. MSCDM with modified field name and data type DEATH_DATE_IMPUT E varchar(2) B=Both month and day imputed D=Day imputed M=Month imputed N=Not imputed NI=No information UN=Unknown OT=Other When date of death is imputed, this field indicates which parts of the date were imputed. MSCDM with modified field name and value set DEATH_DATE_IMPUTE_ DESCRIPTION Varchar(50) Same as above Description of the death date impute value. DEATH_SOURCE varchar(2) L=Other, locally defined N=National Death Index D=Social Security S=State Death files T=Tumor data NI=No information UN=Unknown OT=Other DEATH_SOURCE_DESC RIPTION Other, locally defined is used to indicate presence of deaths reported from EHR systems, such as in-patient hospital deaths or dead on arrival. MSCDM with modified field name and additional guidance Varchar(50) See values above Source of death description. CDM Page 94

95 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source DEATH_MATCH_CON FIDENCE varchar(2) E=Excellent F=Fair P=Poor NI=No information UN=Unknown OT=Other For situations where a probabilistic patient matching strategy is used, this field indicates the confidence that the patient drawn from external source data represents the actual patient. Should not be present where DEATH_SOURCE is L (locally-defined). May not be applicable for DEATH_SOURCE=T (tumor registry data) MSCDM with modified field name and additional guidance DEATH_MATCH_CON FIDENCE_DESCRIPITION Varchar(50) See values above Description of the death match confidence level. Should not be present where DEATH_SOURCE is L (locally-defined). May not be applicable for DEATH_SOURCE=T (tumor registry data) SITEID varchar(20). Site provenance field for internal use by. CDM Page 95

96 3.14 Table: DEATH_CAUSE DEATH_CAUSE Domain Description: The individual causes associated with a reported death. Relational Integrity: The DEATH_CAUSE table contains one record per unique combination of PATID, DEATH_CAUSE, DEATH_CAUSE_CODE, DEATH_CAUSE_TYPE, and DEATH_CAUSE_SOURCE. Composite Primary Key: PATID, DEATH_CAUSE, DEATH_CAUSE_CODE, DEATH_CAUSE_TYPE, DEATH_CAUSE_SOURCE Foreign Key: DEATH_CAUSE.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) Constraints: PATID (required, not null) DEATH_CAUSE (required, not null) DEATH_CAUSE_CODE (required, not null) DEATH_CAUSE_TYPE (required, not null) DEATH_CAUSE_SOURCE (required, not null) PATID + DEATH_CAUSE + DEATH_CAUSE_CODE + DEATH_CAUSE_TYPE + DEATH_CAUSE_SOURCE (unique) CDM Page 96

97 DEATH_CAUSE Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields PATID nvarchar(36). Arbitrary person-level identifier used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier from the source system. DEATH_CAUSE nvarchar(8). Cause of death code. Decimal point in ICD codes (if any) are included. DEATH_CAUSE_CODE char(2) 09=ICD-9 Cause of death code type. 10=ICD-10 NI=No information UN=Unknown OT=Other Source MSCDM MSCDM with modified field name MSCDM with modified field name DEATH_CAUSE_CODE_DES CRIPTION Varchar(50) See values above Cause of death code description. DEATH_CAUSE_TYPE char(2) C=Contributory I=Immediate/Primary O=Other U=Underlying NI=No information UN=Unknown OT=Other Cause of death type. There should be only one underlying cause of death. MSCDM with modified field name DEATH_CAUSE_TYPE_DESC RIPTION Varchar(50) Same as above Description for cause of death type. DEATH_CAUSE_SOURCE char(2) L=Other, locally defined N=National Death Index D=Social Security S=State Death files T=Tumor data NI=No information UN=Unknown OT=Other Source of cause of death information. Other, locally defined is used to indicate presence of deaths reported from EHR systems, such as in-patient hospital deaths or dead on arrival. MSCDM with modified field name CDM Page 97

98 Field Name DEATH_CAUSE_SOURCE_D ESCRIPTION SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source Varchar(50) See values above Description for source of death. DEATH_CAUSE_CONFIDE NCE char(2) E=Excellent F=Fair P=Poor NI=No information UN=Unknown OT=Other Confidence in the accuracy of the cause of death based on source, match, number of reporting sources, discrepancies, etc. MSCDM with modified field name DEATH_CAUSE_CONFIDE NCE_DESCRIPTION Varchar(50) See values above Death cause confidence description. SITEID varchar(20). Site provenance field for internal use by. CDM Page 98

99 3.15 Table: SURGICAL HISTORY ( only) SURGICAL HISTORY Domain Description: Patient s self-reported history of past surgical procedures. Relational Integrity: The SURGICAL_HISTORY table contains one record per SURGICALHISTORYID. Primary Key: SURGICALHISTORYID Foreign Keys: SURGICAL_HISTORY.PATID is a foreign key to DEMOGRAPHIC.PATID (one-to-many relationship) Constraints: SURGICALHISTORYID (unique, required, not null) PATID (required, not null) PX (required, not null) PX_TYPE (required, not null) Additional Notes: The patient reported surgical history domain is currently not represented in the CDM v3.0, thus this table is specific to the implementation of the CDM. Currently contains a limited amount of data from certain data partners, more data will be added as it becomes available. Data contained in this and other specific tables is currently available for internal analysis, not available for distributed queries. SURGICAL_HISTORY Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields SURGICALHISTORYID bigint. Arbitrary identifier for each unique record. Not persistent across refreshes. Source PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. CDM Page 99

100 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RAW_PATID nvarchar(36). Raw patient level identifier from the source system. SAS_SURGICAL_HIST ORY_DATE Int. SAS data value. Represents the number of days between January 1, 1960, and the surgical history date. SURGICAL_HISTORY_ DATE date. Patient reported date of surgical procedure. SAS_PX_DATE Int. SAS data value. Represents the number of days between January 1, 1960, and the procedure date. PX_DATE nvarchar(400). Date on which the procedure was performed (full date, partial date or textual) PX nvarchar(50). Procedure code PX_TYPE varchar(2). Procedure code type PX_TYPE_DESCRIPTI varchar(40). Textual description of the procedure code type ON PX_DESCRIPTION nvarchar(300). Textual description of procedure code SURGICAL_HX_SOUR CE SURGICAL_HX_SOUR CE_DESCRIPTION varchar(50). Surgical history source Varchar(16). Descriptionof the surgical history source SITEID varchar(20). Site provenance field for internal use by. CDM Page 100

101 3.16 Table: HARVEST HARVEST Domain Description: Attributes associated with the specific CDM implementation. Relational Integrity: The HARVEST table contains one record per unique combination of NETWORKID and DATAMARTID. Composite Primary Key: NETWORKID, DATAMARTID Constraints: NETWORKID (required, not null) DATAMARTID (required, not null) NETWORKID + DATAMARTID (unique) Additional Notes: The HARVEST table contains information about the network, data-mart, and data refreshes. This allows these data to be included in query activity, which can include considerations of data latency. Imputation refers to the practice of adding day or month precision for incomplete dates (i.e. where a specific day or specific month is not present). Please see section 3.1 for further details. Obfuscation, also known as date shifting, is a technique not recommended within. However, where this practice exists, this table allows the situation to be recognized for analytic consideration. Definitions of imputation and obfuscation for dates: o No imputation or obfuscation : For any and every date value that is present, no methods of imputation and/or obfuscation have been applied. This does not imply that every record has a date value. o Imputation for incomplete dates : Some or all date values were imputed from incomplete dates, but no obfuscation was performed. o Date obfuscation : Some or all date values were obfuscated, but no imputation of incomplete dates was performed. Obfuscation can also be called shifting or masking. o Both imputation and obfuscation : Some or all date values were imputed, and some or all date values were obfuscated (does not necessarily need to be on the same record). CDM Page 101

102 HARVEST Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source NETWORKID varchar(10). This identifier is assigned by DSSNI operations NETWORK_NAME varchar(20). Descriptive name of the network DATAMARTID varchar(10). This identifier is assigned by DSSNI operations DATAMART_NAME varchar(20). Descriptive name of the data-mart DATAMART_PLATFORM varchar(2) 01=SQL Server 02=Oracle 03=PostgreSQL 04=MySQL 05=SAS NI=No information UN=Unknown OT=Other CDM_VERSION numeric(12,4). Version currently implemented within this datamart (for example, 1.0, 2.0, 3.0, etc.) DATAMART_CLAIMS varchar(2) 01=Not present 02=Present NI=No information UN=Unknown OT=Other Data-mart includes claims data source(s) DATAMART_EHR varchar(2) 01=Not present 02=Present NI=No information UN=Unknown OT=Other Data-mart includes EHR data source(s) CDM Page 102

103 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source BIRTH_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other ENR_START_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other ENR_END_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the BIRTH_DATE field on the DEMOGRAPHIC table. Data management strategy currently present in the ENR_START_DATE field on the ENROLLMENT table. Data management strategy currently present in the ENR_END_DATE field on the ENROLLMENT table. CDM Page 103

104 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source ADMIT_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other DISCHARGE_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the ADMIT_DATE field on the ENCOUNTER table. Data management strategy currently present in the DISCHARGE_DATE field on the ENCOUNTER table. PX_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the PX_DATE field on the PROCEDURES table. CDM Page 104

105 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RX_ORDER_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the RX_ORDER_DATE field on the PRESCRIBING table. RX_START_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the RX_START_DATE field on the PRESCRIBING table. RX_END_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the RX_END_DATE field on the PRESCRIBING table. CDM Page 105

106 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source DISPENSE_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the DISPENSE_DATE field on the DISPENSING table. LAB_ORDER_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the LAB_ORDER_DATE field on the LAB_RESULT_CM table. SPECIMEN_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the SPECIMEN_DATE field on the LAB_RESULT_CM table. CDM Page 106

107 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RESULT_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the RESULT_DATE field on the LAB_RESULT_CM table. MEASURE_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the MEASURE_DATE field on the VITAL table. ONSET_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the ONSET_DATE field on the CONDITION table. CDM Page 107

108 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source REPORT_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the REPORT_DATE field on the CONDITION table. RESOLVE_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the RESOLVE_DATE field on the CONDITION table. PRO_DATE_MGMT varchar(2) 01=No imputation or obfuscation 02=Imputation for incomplete dates 03=Date obfuscation 04=Both imputation and obfuscation NI=No information UN=Unknown OT=Other Data management strategy currently present in the PRO_DATE field on the PRO_CM table. CDM Page 108

109 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source REFRESH_DEMOGRAPHIC _DATE Date. Most recent date on which the present data were loaded into the DEMOGRAPHIC table. This date should be null if the table does not have records. REFRESH_ENROLLMENT_ DATE REFRESH_ENCOUNTER_D ATE Date. Most recent date on which the present data were loaded into the ENROLLMENT table. This date is null if the table does not have records. Date. Most recent date on which the present data were loaded into the ENCOUNTER table. This date is null if the table does not have records. REFRESH_DIAGNOSIS_DA TE REFRESH_PROCEDURES_ DATE Date. Most recent date on which the present data were loaded into the DIAGNOSIS table. This date is null if the table does not have records. Date. Most recent date on which the present data were loaded into the PROCEDURES table. This date is null if the table does not have records. REFRESH_VITAL_DATE Date. Most recent date on which the present data were loaded into the VITAL table. This date is null if the table does not have records. REFRESH_DISPENSING_D ATE Date. Most recent date on which the present data were loaded into the DISPENSING table. This date is null if the table does not have records. REFRESH_LAB_RESULT_C M_DATE Date. Most recent date on which the present data were loaded into the LAB_RESULT_CM table. This date is null if the table does not have records. CDM Page 109

110 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source REFRESH_CONDITION_DA TE Date. Most recent date on which the present data were loaded into the CONDITION table. This date is null if the table does not have records. REFRESH_PRO_CM_DATE Date. Most recent date on which the present data were loaded into the PRO_CM table. This date is null if the table does not have records. REFRESH_PRESCRIBING_ DATE Date. Most recent date on which the present data were loaded into the PRESCRIBING table. This date is null if the table does not have records. REFRESH_PCORNET_TRIA L_DATE Date. Most recent date on which the present data were loaded into the PCORNET_TRIAL table. This date is null if the table does not have records. REFRESH_DEATH_DATE Date. Most recent date on which the present data were loaded into the DEATH table. This date is null if the table does not have records. REFRESH_DEATH_CAUSE _DATE Date. Most recent date on which the present data were loaded into the DEATH_CAUSE table. This date is null if the table does not have records. CDM Page 110

111 3.17 Table: Immunization IMMUNIZATION Domain Description: Immunizations ordered and administered within the context of healthcare delivery; it also contains historical, patient-reported immunizations administered elsewhere. For OCHIN-Epic, this only includes immunizations with a status of Given. IMMUNIZATION Table Specification Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source IMMUNIZATION_ID bigint. Arbitrary identifier for each unique record. Not persistent across refreshes. PATID nvarchar(36). Arbitrary person-level identifier. Used to link across tables. RAW_PATID nvarchar(36). Raw patient level identifier in the source system(s). HEALTH_SYSTEM_ID varchar(50). Unique health system identifier. For OCHIN data this represents the numeric service area ID, whereas for HCN this represents the alphanumeric member center ID. HEALTH_SYSTEM_N AME varchar(300). The health system name, either OCHIN service areas or HCN centers.. FACILITYID nvarchar(36). FACILITYID is a pseudo-identifier with a consistent crosswalk to the true identifier. RAW_FACILITYID nvarchar(400). Raw facility id level identifier from the source system. For OCHIN records this corresponds to the Epic department ID, whereas for HCN records this represents the care delivery site ID. FACILITY_NAME nvarchar(400). Name of the facility as noted in the source system(s). CDM Page 111

112 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source ENCOUNTERID nvarchar(36). Arbitrary encounter-level identifier. Used to link records across tables, including the ENCOUNTER, DIAGNOSIS, and PROCEDURES tables. RAW_ENCOUNTERID nvarchar (200) Raw encounter level identifier from the source system(s). IMMUNIZATION_DAT E SAS_IMMUNIZATION_ DATE date The date the immunization was administered. int SAS data value. Represents the number of days between January 1, 1960, and the immunization date. CVX_CODE varchar (50) The CVX code assigned to the immunization. CVX codes indicate the product used in a vaccination, these standard codes are maintained by the CDC for use in HL7 data transmission. CPT_CODE varchar (50) The CPT code assigned to the immunization. OCHIN note: CPT codes are only directly available for immunizations ordered and administered by the OCHIN clinics, OCHIN maintain crosswalks in Epic that map the internal immunization Epic IDs to CPT and/or CVX codes, these in turn are used by the immunization HL7 interfaces. CDC CDC - AMA ROUTE varchar (400) Intra-Articular Intradermal Intramuscular Intranasal Intravenous Oral Subcutaneous Sublingual The immunization administration route. ORDER_DATE date For immunizations ordered and administered by the health center (non-historical), this is the date when the immunization order was placed. CDM Page 112

113 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source SAS_ORDER_DATE int SAS data value. Represents the number of days between January 1, 1960, and the immunization order date. ORDER_STATUS varchar (400) Completed Resulted Sent Canceled For immunizations ordered and administered by the health center (non-historical), this is the status of the immunization order. VACCINE_LOT_NUMB ER varchar (100) The lot number of the vaccine. EXPIRATION_DATE date The vaccine s expiration date. SAS_EXPIRATION_D ATE int SAS data value. Represents the number of days between January 1, 1960, and the vaccine expiration date. MANUFACTURER_NA ME varchar (400) The vaccine s manufacturer. The list for OCHIN currently includes over 100 manufacturers, some of the most common are: Sanofi Pasteur, Merck and Co., GlaxoSmithKline, Wyeth Pharmaceuticals, etc. ADMINISTRATION_SI TE varchar (400) The location of the injection (if applicable). For example, left deltoid, right deltoid, Left anteriolateral aspect of thigh, Left arm, Oral, etc. DOSE_AMOUNT numeric (12,2) The numeric quantity of the immunization free-text dosage. Only populated for immunization where the free-text dose field contains both dose amount and units (i.e. 0.5 ml ) DOSE_UNITS varchar (50) Caps, CC, G, IU, MG, MG/2ML, MG/ML, ML, Tab, U, UG, UG/ML, Vial The normalized standard units in the immunization free-text dosage. Only populated for immunization where the free-text dose field contains both dose amount and units (i.e. 100 mg ) HISTORICAL_IMMUNI ZATION_YN char (1) Y N Indicates whether the immunization is a historical record, patient-reported immunization (Y), or it was ordered/administered by the health center (N). CDM Page 113

114 Field Name SQL Data Type Predefined Value Sets and Descriptive Text for Categorical Fields Source RAW_IMMUNIZATION _ID varchar(50). The unique identifier of the immunization record in the source system. RAW_IMMUNIZATION _NAME varchar (400). The name of the immunization in the source system. RAW_IMMUNIZATION _SOURCE_ID varchar (50). The unique identifier of the immunization record in the source system. For OCHIN records this represents the primary key field IMMUNE_ID in the IMMUNE table. RAW_DOSE varchar (100) The free-text immunization dosage, in addition to dose values that can be parsed and stored into discrete quantity and standard units (DOSE_AMOUNT and DOSE_UNITS respectively) this field also can contain comments and other values that cannot be normalized into standard units. RAW_ORDER_ID varchar (50) The unique identifier of the order associated with the immunization. For OCHIN data this corresponds to the ORDER_ID field in the IMMUNE Clarity table, which in turn is the link to the ORDER_PROC.ORDER_ID field. SITEID varchar(20). Site provenance field for internal use by. CDM Page 114

115 3.18 Table: FAMILY_LINKAGE FAMILY_LINKAGE Description: This table currently contains the mother s PATID for each PATID in where this relationship has been determined by one or multiple direct and indirect data sources, and algorithms. FAMILY LINKAGE Table Specification Field Name SQL Data Source Type PATID varchar (36) surrogate person-level identifier. MOTHER_PATID varchar (36) Mother s PATID GUARANTOR_MOM int (1/0) A value of 1 indicates an explicit patient-mother relationship documented in the mother s guarantor account(s) information (OCHIN-Epic). EMERGENCY_CONTACT_MOM int (1/0) A value of 1 indicates an explicit patient-mother relationship documented in the patient s emergency contacts information (OCHIN-Epic). COVERAGE_MOM int (1/0) A value of 1 indicates an explicit patient-mother relationship documented in the patient s coverage account(s) information (OCHIN-Epic). OB_CLM_FRM_MOM int (1/0) A value of 1 indicates an explicit patient-mother relationship documented in the mother s OB claim form (OCHIN-Epic Prenatal Care Claim Form). MEDICAID_CASE_NUM_MOM int (1/0) A value of 1 indicates that the patient-mother relationship was imputed using Oregon Medicaid caase number data as the household link (OCHIN-Epic). ADDRESS_MOM int (1/0) A value of 1 indicates that the patient-mother relationship was imputed using exact geocoded coordinates for each patient s last known address as the household link (OCHIN-Epic). HOME_PHONE_MOM int (1/0) A value of 1 indicates that the patient-mother relationship was imputed using home phone number as the household link (OCHIN-Epic). FUZZY_MATCH_MOM int (1/0) A value of 1 indicates that the patient-mother relationship was determined through a fuzzy comparison of free-text mother emergency contact demographics against the entire list of female patients 18 and older in. SITEID varchar(20) Site provenance field for internal use by. CDM Page 115

116 General algorithm for imputed maternal linkages: CDM Page 116

117 Performance test for imputed linkages by common-household data identifier (2/1/2017). The test was performed against a gold standard of 25,534 linkages, defined as explicit maternal linkages noted as both Epic patient ID in emergency contact, and guarantor account family relationships. Algorithm Shared data identifier Gold Standard (TP + FN) TP FP Sensitivity: TP/(Gold Standard) Precision: TP / (TP + FP) DMAP Case Number 25,534 8, Home Phone 25,534 20, Geocoded Address 25,534 4, Fuzzy Matching: For patients without any of the above linkages (explicit or imputed), but who have free-text mother emergency contact information in Epic: mother first name, last name, street address, zip code and/or phone number, a fuzzy comparison of each field is performed against the entire list of female patients 18 and older. A link is determined through this method if the following criteria are met: Patient-mother age difference is between 18 and 43 AND Overall field similarity >= 0.85 AND Overall confidence > 0.5 AND First name similarity > 0.4 AND ( Phone number similarity >= 0.8 OR ( Street address similarity > 0.5 AND Zip code similarity >= 0.8) ) CDM Page 117

118 Appendix A: Glossary of Terms Accelerating Data Value Across a National Community Health Center Network (For more information: ) CDM Common Data Model CDRN Clinical Data Research Network (For more information: ) CVS Community Vital Signs EHR Electronic Health Record ESP Electronic Medical Record Support for Public Health Project (For more information: ) FPL Federal Poverty Level (For more information: ) HIPAA The Health Insurance Portability and Accountability Act (For more information: ) LOINC Logical Observation Identifiers Names and Codes (For more information: ( ) MSCDM Mini-Sentinel Common Data Model (For more information: Data-Model.pdf ) NPPES National Plan & Provider Enumeration System: NUCC National Uniform Claim Committee: OMB Office of Management and Budget (For more information: ) OMOP Observational Medical Outcomes Partnership (For more information: ( ) PCORI Patient-Centered Outcomes Research Institute (For more information: The National Patient-Centered Clinical Research Network (For more information: ) PHI Protected Health Information (For more information: ) PPRN Patient Powered Research Network (For more information: ) PROMIS Patient Reported Outcomes Measurement Information System (For more information: ( ) RDW Research Data Warehouse. The RDW contains all tables and fields from the CDM plus additional tables and fields required for safety net research. RxNorm RxNorm is two things: a normalized naming system for generic and branded drugs; and a tool for supporting semantic interoperation between drug terminologies and pharmacy knowledge base systems. The National Library of Medicine (NLM) produces RxNorm. (For more information: ) UDS Uniform Data System (For more information: ) ZCTA ZIP Code Tabulation Area (For more information: ) CDM Page 118

119 Appendix B: Community Vital Signs (CVS) About the Robert Graham Center and HealthLandscape The Robert Graham Center exists to improve individual and population health by enhancing the delivery of primary care. The Center aims to achieve this vision through the generation or synthesis of evidence that brings a family medicine and primary care perspective to health policy deliberations from the local to international levels. HealthLandscape develops geospatial analysis software tools and offers professional services, as needed, to support those applications. In existence since 2008, HealthLandscape designs, develops, and deploys interactive web applications that allow public users, policy makers, academic researchers, and planners to combine, analyze, and display information in ways that promote understanding. HealthLandscape also acquires, catalogs, and routinely updates an extensive data library of social, behavioral, economic, and health related data as part of the HealthLandscape Platform. Over 2 million current and historical addresses for all OCHIN patients enrolled in have been geo-coded using the Community Vital Signs (CVS) platform. As part of this geocoding process geographic indicators, such as latitude, longitude, ZCTA, tract and county, have been determined for each address and the following list of pre-determined community indicators, called community characteristics, have been appended to each record. By design, these data are not currently part of the CDM, but can be easily linked to the CDM patient IDs. CDM Page 119

120 CVS Measures Geographic Availabilty Domain Source Indicator Period County Tract Tract Built Environment American Community Survey [ACS_PopDens] Population Density [ACS_SQMI] Square Miles [ACS_TotPop] Total Population [ACS_TOTPOP] Total Population [All_SizeHH_Total] Total households - All sizes [FourPlusPerHH_Total] Total 4-person households [OnePerHH_Total] Total 1-person households [ThreePerHH_Total] Total 3-person households [TwoPerHH_Total] Total 2-person households [CBP_FastFood] Fast Food Restaurants per 100, [CBP_FastFoodCount] Number of Fast Food Restaurants County/ZIP Code Business Patterns [CBP_Liquor] Liquor Stores per 100, [CBP_LiquorCount] Number of Liquor Stores [DM_PctA1cTest] Average annual percent of diabetic Medicare enrollees age65-75 having hemoglobin A1ctest 2012 Clinical Care Dartmouth Atlas [DM_PctEyeExam] Average annual percent of diabetic Medicare enrollees age65-75 having eye examination 2012 [DM_PctLDLTest] Average annual percent of diabetic Medicare enrollees age65-75 having blood lipids (LDL-C) test American Environmental [ACS_completeplumb] Percent of Occupied Housing Units Community Exposures without Complete Plumbing Facilities Survey CDM Page 120

121 Environmental Protection Agency; CDC Environment Public Health Tracking Network Environmental Protection Agency; SOWIS; RWJ County Health Rankings [ACS_medagestrct] Median Housing Structure Age [EPHTN_OznPrsnDysAbvStd] Ozone (Number of person-days with maximum 8-hour average ozone concentration over the National Ambient Air Quality Standard (monitor and modeled data) over National Standards 2008 [EPHTN_PMPrsnDysAbvStd] Particulate Matter (Number of person-days with maximum 8- hour average PM 2.5 concentration over the National Ambient Air Quality Standard (monitor and modeled data) over National Standards [SDWIS_WtrViol] Water Quality (Percent of population potentially exposed to water exceeding a violation limit during the past year) [ACS_NUM_ALLOTHHISP] Number all other Hispanic or Latino [ACS_NUM_ARGENTIN] Number Argentinean [ACS_NUM_BOLIVIAN] Number Bolivian [ACS_NUM_CHILEAN] Number Chilean [ACS_NUM_COLOMBIAN] Number Colombian Hispanic or [ACS_NUM_CRICA] Number Costa Rican American Latino Origin [ACS_NUM_CUBAN] Number Cuban Community by Specific [ACS_NUM_DOMINICAN] Number Dominican Survey Origin [ACS_NUM_ECUADORIAN] Number Ecuadorian [ACS_NUM_GUATEMALEN] Number Guatemalan [ACS_NUM_HONDURAN] Number Honduran [ACS_NUM_MEXICAN] Number Mexican [ACS_NUM_NIGARAGUAN] Number Nicaraguan CDM [ACS_NUM_OTHCTRLAMR] Number Other Central American Page 121

122 [ACS_NUM_OTHSTHAMR] Number Other South American [ACS_NUM_PANAMANIAN] Number Panamanian [ACS_NUM_PARAGUAYAN] Number Paraguayan [ACS_NUM_PERUVIAN] Number Peruvian [ACS_NUM_PRICAN] Number Puerto Rican [ACS_NUM_SALVADORAN] Number Salvadoran [ACS_NUM_SPANAMER] Number Spanish American [ACS_NUM_SPANIARD] Number Spaniard [ACS_NUM_SPANISH] Number Spanish [ACS_NUM_URUGUAYAN] Number Uruguayan [ACS_NUM_VENEZUELAN] Number Venezuelan [ACS_PCT_ALLOTHHISP] Percent all other Hispanic or Latino [ACS_PCT_ARGENTIN] Percent Argentinean [ACS_PCT_BOLIVIAN] Percent Bolivian [ACS_PCT_CHILEAN] Percent Chilean [ACS_PCT_COLOMBIAN] Percent Colombian [ACS_PCT_CRICA] Percent Costa Rican [ACS_PCT_CUBAN] Percent Cuban [ACS_PCT_DOMINICAN] Percent Dominican [ACS_PCT_ECUADORIAN] Percent Ecuadorian [ACS_PCT_GUATEMALEN] Percent Guatemalan [ACS_PCT_HONDURAN] Percent Honduran [ACS_PCT_MEXICAN] Percent Mexican [ACS_PCT_NIGARAGUAN] Percent Nicaraguan [ACS_PCT_OTHCTRLAMR] Percent Other Central American [ACS_PCT_OTHSTHAMR] Percent Other South American [ACS_PCT_PANAMANIAN] Percent Panamanian [ACS_PCT_PARAGUAYAN] Percent Paraguayan [ACS_PCT_PERUVIAN] Percent Peruvian [ACS_PCT_PRICAN] Percent Puerto Rican [ACS_PCT_SALVADORAN] Percent Salvadoran [ACS_PCT_SPANAMER] Percent Spanish American [ACS_PCT_SPANIARD] Percent Spaniard [ACS_PCT_SPANISH] Percent Spanish CDM [ACS_PCT_URUGUAYAN] Percent Uruguayan Page 122

123 Hospital Utilization Centers for Medicare & Medicaid (Geographic Variation PUF) Dartmouth Atlas Agency for Toxic Substances and Disease Registry (ATSDR) [ACS_PCT_VENEZUELAN] Percent Venezuelan [CMS_EDVisits] ED Visits per 1,000 Enrollees 2012 [CMS_Readmissions] % readmissions within 30 days of hospital visit 2012 [DM_ACSCDischarges] Discharges for ambulatory care sensitive conditions per 1,000 Medicare enrollees 2012 [ATSDR_SVI] Overall Percent Ranking for Social Vulnerability Index (SVI) [ACS_DpndRtoOLD] Dependency Ratio (Old-Age) Neighborhood Economic Conditions American [ACS_DpndRtoTOTAL] Dependency Ratio Community Survey [ACS_DpndRtoYOUNG] Dependency Ratio (Young) [ACS_GINI] GINI Income Inequality CDM Page 123

124 US Department of Housing & Urban Development, Neighborhood Stabilization Program [HUD_EstForeclosureRate] Estimated percent of foreclosure starts over past 18 months (June2008) 2008 [HUD_EstVacancyRate] Estimated Percent of vacant addresses in June 2008 (90-day vacancy rate) 2008 [ACS_NumAmerInd] Number American Indian/Alaskan Native [ACS_NumAmerInd] Number American Indian/Alaskan Native [ACS_NumAmerInd] Number American Indian/Alaskan Native [ACS_NumAmerInd] Number American Indian/Alaskan Native [ACS_NumAmerInd] Number American Indian/Alaskan Native Neighborhood American [ACS_NumAmerInd] Number American Indian/Alaskan Native Race/Ethnic Community Composition Survey [ACS_NumAmerInd] Number American Indian/Alaskan Native [ACS_NumAsians] Number Asians [ACS_NumBlackAlone] Number Black Alone CDM Page 124

125 [ACS_NumHispanic] Number Hispanic [ACS_NumHispanicNW] Number Hispanic Non-white [ACS_NumNHOPI] Number Hawaiian/Pacific Islander [ACS_NumNonWhite] Number Non-white [ACS_NumWhiteAlone] Number White Alone CDM [ACS_pctAmerInd] Percent American Indian/Alaskan Native Page 125

126 [ACS_pctAsians] Percent Asians [ACS_pctBlackAlone] Percent Black Alone [ACS_pctHispanic] Percent Hispanic [ACS_PCTHispanicNW] Percent Hispanic Non-white [ACS_pctNHOPI] Percent Hawaiian/Pacific Islander CDM Page 126

127 [ACS_pctNonWhite] Percent Non-white [ACS_pctWhiteAlone] Percent White Alone CDM [ResSegWHITEDAIAN] Residential Segregation: Dissimilarity White/American Indian, Alaskan Native [ResSegWHITEDASIAN] Residential Segregation: Dissimilarity White/Asian [ResSegWHITEDBLACK] Residential Segregation: Dissimilarity White/Black [ResSegWHITEDMULT] Residential Segregation: Dissimilarity White/Multiple Races Page 127

128 [ResSegWHITEDNHOPI] Residential Segregation: Dissimilarity White/Native Hawaiian, Pacific Islander [ResSegWHITEDOTHER] Residential Segregation: Dissimilarity White/Other Race [ResSegXAIAN] Residential Segregation: Exposure American Indian, Alaskan Native [ResSegXASIAN] Residential Segregation: Exposure - Asian [ResSegXBLACK] Residential Segregation: Exposure - Black [ResSegXMULT] Residential Segregation: Exposure Multiple Races [ResSegXNHOPI] Residential Segregation: Exposure Native Hawaiian, Pacific Islander CDM Page 128

129 Neighborhood Resources Centers for Disease Controland Prevention, National Environmental Public Health Tracking Network: County/ZIP Code Business Patterns Robert Graham Center U.S. Census Bureau USDA Food Access ResearchAtlas [ResSegXOTHER] Residential Segregation: Exposure Other Race [ResSegXWHITE] Residential Segregation: Exposure White [EPHTN_AccessParks] Access to Parks (Percent of population within ½ mile of a park) [CBP_RecFacs] Recreational Facilities per 100, [CBP_RecFacsCount] Number of Recreational Facilities [SDI] Social Deprivation Index 2015 [SDI_SCORE] Social Deprivation Index Score 2015 [USDA_UrbanRural] Urban Classification Code - Rural, Urban Cluster (greater than 10,000 population, less than 50,000 population), Urban Area (greater than 50,000 population) 2010 [USDA_Acc1Mile] Low access tract at 1 mile for urban areas or 10 miles for rural areas 2010 [USDA_AccHalfMile] Low access tract at 1/2 mile for urban areas or 10 miles for rural areas 2010 [USDA_FoodAccess] Percent of people in a county living more than 1 mile from a supermarket or large grocery store if in an USDA Food Atlas urban area, or more than 10 miles from a supermarket or large grocery store if in a rural area 2010 USDA, ERS [USDA_RUCC] Metro/Non Metro Classification Codes 2013 CDM Page 129

130 Neighborhood Socioeconomic Composition American Community Survey [USDA_RUCCDesc] Metro/Non Metro Classification [ACS_MedHHIncome] Median household income [ACS_NumCollGrad] Number of persons with a Bachelor s Degree or Higher [ACS_NumMngrPrfsnl] Number of persons in managerial, professional, or executive occupations [ACS_pctCollGrad] Percent of persons with a Bachelor s Degree or Higher [ACS_PctMngrPrfsnl] Percent of persons in managerial, professional, or executive occupations CDM Page 130

131 Neighborhood Transportation Resources American Community Survey [ACS_pctPoverty100] Poverty level (Below 100% FPL) [ACS_pctPoverty200] Low-Income (Below 200% FPL) [ACS_Unemployment] Unemployment rate [All_SizeHH_AnyVehicle] Number of households with one or more vehicles [All_SizeHH_NoVehicle] Number of households without vehicle [All_SizeHH_pctAnyVehicle] Percent of households with one or more vehicles [All_SizeHH_pctNoVehicle] Percent of households without vehicle [FourPlusPerHH_AnyVehicle] Number of 4-person households with one or more vehicles [FourPlusPerHH_NoVehicle] Number of 4-person households without vehicle CDM Page 131

132 Preventive Care Dartmouth Atlas [FourPlusPerHH_pctAnyVehicle] Percent of 4-person households with one or more vehicles [FourPlusPerHH_pctNoVehicle] Percent of 4-person households without vehicle [OnePerHH_AnyVehicle] Number of 1-person households with one or more vehicles [OnePerHH_NoVehicle] Number of 1-person households without vehicle [OnePerHH_pctAnyVehicle] Percent of 1-person households with one or more vehicles [OnePerHH_pctNoVehicle] Percent of 1-person households without vehicle [ThreePerHH_AnyVehicle] Number of 3-person households with one or more vehicles [ThreePerHH_NoVehicle] Number of 3-person households without vehicle [ThreePerHH_pctAnyVehicle] Percent of 3-person households with one or more vehicles [ThreePerHH_pctNoVehicle] Percent of 3-person households without vehicle [TwoPerHH_AnyVehicle] Number of 2-person households with one or more vehicles [TwoPerHH_NoVehicle] Number of 2-person households without vehicle [TwoPerHH_pctAnyVehicle] Percent of 2-person households with one or more vehicles [TwoPerHH_pctNoVehicle] Percent of 2-person households without vehicle [DM_AnnualPCPVisit] Average annual percent of Medicare enrollees having at least one ambulatory visit to a primary care clinician 2012 [DM_PctMammogram] Average percent of female Medicare enrollees age having at least one mammogram over a two-year period 2012 CDM Page 132

133 Appendix C: Data Completeness Summary As of 4/26/2017: Null Count: The number of rows where the value for the corresponding column is either Null, NI or Blank (for more details see section 3.1 HL7 conventions for missing or unknown data values). Table Column Null Count Total Rows % Completene ss Distinct Column Values CONDITION RESOLVE_DATE 20,362,407 23,058, % 5,920 CONDITION ONSET_DATE 3,818,860 23,058, % 10,194 CONDITION ENCOUNTERID 3,626,905 23,058, % 8,328,042 CONDITION REPORT_DATE 2,504,602 23,058, % 8,866 CONDITION ICD_RUBRIC 257,516 23,058, % 2,937 CONDITION CONDITION_TYPE 75,078 23,058, % 6 CONDITION CONDITION_STATUS 10,310 23,058, % 5 CONDITION CONDITION ,058, % 40,980 CONDITION CONDITION_SOURCE 0 23,058, % 2 CONDITION CONDITIONID 0 23,058, % 23,058,60 8 CONDITION PATID 0 23,058, % 2,817,709 CONDITION SITEID 0 23,058, % 3 DEATH DEATH_MATCH_CONFIDENCE 15,967 15, % 0 DEATH DEATH_DATE_IMPUTE , % 1 DEATH DEATH_DATE 0 15, % 1,958 DEATH DEATH_SOURCE 0 15, % 1 DEATH PATID 0 15, % 15,928 DEATH SITEID 0 15, % 4 DEATH_CAUSE DEATH_CAUSE_CONFIDENCE 5,474 5, % 1 DEATH_CAUSE DEATH_CAUSE 0 5, % 1,641 DEATH_CAUSE DEATH_CAUSE_CODE 0 5, % 2 DEATH_CAUSE DEATH_CAUSE_SOURCE 0 5, % 1 DEATH_CAUSE DEATH_CAUSE_TYPE 0 5, % 1 DEATH_CAUSE PATID 0 5, % 1,359 DEATH_CAUSE SITEID 0 5, % 1 CDM Page 133

134 DEMOGRAPHIC BIRTH_TIME 3,734,594 3,734, % 0 DEMOGRAPHIC FAMILY_LINKAGE_ID 3,734,594 3,734, % 0 DEMOGRAPHIC LAST_VISIT_PC_DEPARTMENT_NAME 3,734,594 3,734, % 0 DEMOGRAPHIC SEXUAL_ORIENTATION 3,632,772 3,734, % 8 DEMOGRAPHIC GENDER_IDENTITY 3,620,787 3,734, % 8 DEMOGRAPHIC CURRENT_PCP_DEPT_ID 2,488,953 3,734, % 542 DEMOGRAPHIC LAST_VISIT_PC_DEPARTMENT_ID 1,935,377 3,734, % 534 DEMOGRAPHIC CURRENT_HOMELESS_STATUS 1,280,036 3,734, % 3 DEMOGRAPHIC CURRENT_MIGRANT_SEASONAL_STATUS 1,264,395 3,734, % 3 DEMOGRAPHIC CURRENT_FPL_PERCENTAGE 985,130 3,734, % 4,183 DEMOGRAPHIC CURRENT_FAMILY_SIZE 701,714 3,734, % 79 DEMOGRAPHIC CURRENT_ANNUAL_INCOME 696,631 3,734, % 103,238 DEMOGRAPHIC CURRENT_PRIMARY_PAYOR 612,969 3,734, % 6,577 DEMOGRAPHIC VETERAN_STATUS 454,982 3,734, % 4 DEMOGRAPHIC RACE 77,800 3,734, % 10 DEMOGRAPHIC PRIMARY_LANGUAGE 67,495 3,734, % 238 DEMOGRAPHIC HISPANIC 56,796 3,734, % 5 DEMOGRAPHIC CURRENT_STATE_OF_RESIDENCE 4,986 3,734, % 103 DEMOGRAPHIC CURRENT_PAYOR_MILITARY 3,107 3,734, % 2 DEMOGRAPHIC CURRENT_PAYOR_TYPE_RESEARCH 3,107 3,734, % 6 DEMOGRAPHIC CURRENT_PRIMARY_PAYOR_TYPE 3,107 3,734, % 9 DEMOGRAPHIC SEX 519 3,734, % 5 DEMOGRAPHIC CURRENT_PCP_STATUS 239 3,734, % 3 DEMOGRAPHIC BIRTH_DATE 8 3,734, % 36,712 DEMOGRAPHIC BIOBANK_FLAG 0 3,734, % 1 DEMOGRAPHIC PATID 0 3,734, % 3,734,594 DEMOGRAPHIC SITES 0 3,734, % 3 DIAGNOSIS DX_ORIGIN 105,988, ,540, % 1 DIAGNOSIS PDX 24,515, ,540, % 4 DIAGNOSIS DX_SOURCE 19,175, ,540, % 4 DIAGNOSIS ICD_RUBRIC 2,067, ,540, % 3,014 DIAGNOSIS PROVIDERID 171, ,540, % 65,761 DIAGNOSIS ADMIT_DATE 0 106,540, % 5,022 DIAGNOSIS DIAGNOSISID 0 106,540, % 106,540,9 CDM 43 Page 134

135 DIAGNOSIS DX 0 106,540, % 50,455 DIAGNOSIS DX_TYPE 0 106,540, % 3 DIAGNOSIS ENC_TYPE 0 106,540, % 6 DIAGNOSIS ENCOUNTERID 0 106,540, % 53,798,92 3 DIAGNOSIS PATID 0 106,540, % 3,695,191 DIAGNOSIS SITEID 0 106,540, % 5 DISPENSING PRESCRIBINGID 53,831,299 53,831, % 0 DISPENSING DISPENSE_AMT ,831, % 2,092 DISPENSING DISPENSE_DATE 0 53,831, % 2,096 DISPENSING DISPENSE_SUP 0 53,831, % 389 DISPENSING DISPENSINGID 0 53,831, % 53,831,29 9 DISPENSING NDC 0 53,831, % 59,065 DISPENSING PATID 0 53,831, % 1,262,691 DISPENSING SITEID 0 53,831, % 2 ENCOUNTER DRG_TYPE 83,733,868 83,972, % 1 ENCOUNTER DRG 83,663,850 83,972, % 834 ENCOUNTER ADMITTING_SOURCE 83,594,382 83,972, % 9 ENCOUNTER DISCHARGE_TIME 83,592,113 83,972, % 1,440 ENCOUNTER DISCHARGE_DISPOSITION 83,590,688 83,972, % 4 ENCOUNTER DISCHARGE_DATE 83,480,157 83,972, % 2,345 ENCOUNTER DISCHARGE_STATUS 81,950,855 83,972, % 12 ENCOUNTER HOMELESS_STATUS 69,642,826 83,972, % 3 ENCOUNTER MIGRANT_SEASONAL_STATUS 68,694,607 83,972, % 3 ENCOUNTER ANNUAL_INCOME 67,164,970 83,972, % 55,288 ENCOUNTER FAMILY_SIZE 67,122,963 83,972, % 169 ENCOUNTER LEVEL_OF_SERVICE 64,204,493 83,972, % 983 ENCOUNTER FPL_PERCENTAGE 50,040,866 83,972, % 7,043 ENCOUNTER PRIMARY_PAYOR 44,467,503 83,972, % 8,988 ENCOUNTER PRIMARY_PAYOR_TYPE 39,037,017 83,972, % 14 ENCOUNTER PAYOR_MILITARY 39,037,015 83,972, % 2 ENCOUNTER PAYOR_TYPE_RESEARCH 39,037,015 83,972, % 6 ENCOUNTER FACILITY_LOCATION 18,877,977 83,972, % 120 ENCOUNTER FACILITYID 15,346,388 83,972, % 2,972 ENCOUNTER PROVIDERID 689,552 83,972, % 70,024 CDM Page 135

136 ENCOUNTER ADMIT_DATE 0 83,972, % 5,688 ENCOUNTER ADMIT_TIME 0 83,972, % 1,440 ENCOUNTER ENC_TYPE 0 83,972, % 6 ENCOUNTER ENCOUNTERID 0 83,972, % 83,972,46 4 ENCOUNTER PATID 0 83,972, % 3,734,594 ENCOUNTER SITEID 0 83,972, % 5 ENROLLMENT ENR_END_DATE 3,080,105 3,767, % 836 ENROLLMENT CHART 0 3,767, % 1 ENROLLMENT ENR_BASIS 0 3,767, % 1 ENROLLMENT ENR_START_DATE 0 3,767, % 1,930 ENROLLMENT PATID 0 3,767, % 3,734,586 ENROLLMENT SITEID 0 3,767, % 3 IMMUNIZATION NDC_CODE 10,707,152 12,823, % 771 IMMUNIZATION ORDER_STATUS 8,877,526 12,823, % 4 IMMUNIZATION DOSE_AMOUNT 8,777,314 12,823, % 677 IMMUNIZATION DOSE_UNITS 8,777,314 12,823, % 13 IMMUNIZATION EXPIRATION_DATE 8,639,494 12,823, % 5,584 IMMUNIZATION ORDER_DATE 8,634,487 12,823, % 3,826 IMMUNIZATION ADMINISTRATION_SITE 8,522,956 12,823, % 46 IMMUNIZATION MANUFACTURER_NAME 8,514,134 12,823, % 105 IMMUNIZATION ROUTE 8,157,919 12,823, % 8 IMMUNIZATION VACCINE_LOT_NUMBER 8,151,842 12,823, % 123,576 IMMUNIZATION ENCOUNTERID 7,498,493 12,823, % 2,576,306 IMMUNIZATION CVX_CODE 359,426 12,823, % 123 IMMUNIZATION CPT_CODE 78,654 12,823, % 246 IMMUNIZATION FACILITYID 0 12,823, % 770 IMMUNIZATION HEALTH_SYSTEM_ID 0 12,823, % 100 IMMUNIZATION HISTORICAL_IMMUNIZATION_YN 0 12,823, % 2 IMMUNIZATION IMMUNIZATION_DATE 0 12,823, % 17,221 IMMUNIZATION PATID 0 12,823, % 1,144,971 IMMUNIZATION SITEID 0 12,823, % 1 LAB_RESULT_CM RESULT_UNIT 255,245, ,596, % 6 LAB_RESULT_CM NORM_MODIFIER_HIGH 255,232, ,596, % 5 LAB_RESULT_CM NORM_MODIFIER_LOW 255,232, ,596, % 4 CDM Page 136

137 LAB_RESULT_CM NORM_RANGE_LOW 255,120, ,596, % 55 LAB_RESULT_CM NORM_RANGE_HIGH 255,075, ,596, % 92 LAB_RESULT_CM LAB_NAME 237,667, ,596, % 12 LAB_RESULT_CM ABN_IND 234,933, ,596, % 10 LAB_RESULT_CM RESULT_QUAL 187,612, ,596, % 5 LAB_RESULT_CM SPECIMEN_SOURCE 126,181, ,596, % 9 LAB_RESULT_CM LAB_LOINC 113,172, ,596, % 5,978 LAB_RESULT_CM PRIORITY 111,793, ,596, % 5 LAB_RESULT_CM LAB_PX 111,497, ,596, % 5,575 LAB_RESULT_CM LAB_PX_TYPE 111,497, ,596, % 6 LAB_RESULT_CM RESULT_LOC 109,200, ,596, % 3 LAB_RESULT_CM ENCOUNTERID 76,896, ,596, % 10,469,08 7 LAB_RESULT_CM RESULT_NUM 75,536, ,596, % 136,198 LAB_RESULT_CM SPECIMEN_TIME 11,818, ,596, % 1,440 LAB_RESULT_CM SPECIMEN_DATE 7,944, ,596, % 6,450 LAB_RESULT_CM LAB_ORDER_DATE 4,456, ,596, % 6,526 LAB_RESULT_CM RESULT_MODIFIER 3,780, ,596, % 6 LAB_RESULT_CM LAB_RESULT_CM_ID 0 255,596, % 255,596,8 69 LAB_RESULT_CM PATID 0 255,596, % 2,378,572 LAB_RESULT_CM RESULT_DATE 0 255,596, % 6,959 LAB_RESULT_CM RESULT_TIME 0 255,596, % 1,977 LAB_RESULT_CM SITEID 0 255,596, % 4 PRESCRIBING RX_DOSE_NUM 46,246,564 46,246, % 0 PRESCRIBING RX_DOSE_UNIT 46,246,564 46,246, % 0 PRESCRIBING RX_QUANTITY_UNIT 45,463,268 46,246, % 14 PRESCRIBING RX_DAYS_SUPPLY 31,288,751 46,246, % 244 PRESCRIBING RX_ORDER_TIME 30,110,051 46,246, % 1,722 PRESCRIBING RX_FREQUENCY 13,044,190 46,246, % 10 PRESCRIBING RX_END_DATE 9,448,334 46,246, % 8,966 PRESCRIBING RX_REFILLS 3,524,427 46,246, % 166 PRESCRIBING RX_QUANTITY 2,220,471 46,246, % 1,638 PRESCRIBING ENCOUNTERID 2,083,598 46,246, % 22,932,76 4 PRESCRIBING RXNORM_CUI 2,014,849 46,246, % 15,719 CDM Page 137

138 PRESCRIBING RX_PROVIDERID 665,111 46,246, % 13,065 PRESCRIBING RX_BASIS 591,441 46,246, % 2 PRESCRIBING RX_ORDER_DATE 591,441 46,246, % 6,476 PRESCRIBING RX_START_DATE 298,268 46,246, % 6,641 PRESCRIBING PATID 0 46,246, % 2,651,606 PRESCRIBING PRESCRIBINGID 0 46,246, % 46,246,56 4 PRESCRIBING SITEID 0 46,246, % 4 PRO_CM PRO_LOINC 1,058,169 17,180, % 34 PRO_CM ENCOUNTERID 695,482 17,180, % 2,467,244 PRO_CM PRO_METHOD 1,729 17,180, % 3 PRO_CM PRO_MODE 1,729 17,180, % 2 PRO_CM PATID 0 17,180, % 1,094,711 PRO_CM PRO_CAT 0 17,180, % 2 PRO_CM PRO_CM_ID 0 17,180, % 17,180,16 6 PRO_CM PRO_DATE 0 17,180, % 2,994 PRO_CM PRO_ITEM 0 17,180, % 40 PRO_CM PRO_RESPONSE 0 17,180, % 87 PRO_CM PRO_TIME 0 17,180, % 1,633 PRO_CM SITEID 0 17,180, % 3 PROCEDURES PROVIDERID 447, ,813, % 62,921 PROCEDURES PX_SOURCE ,813, % 4 PROCEDURES PX_TYPE ,813, % 9 PROCEDURES ADMIT_DATE 0 104,813, % 5,295 PROCEDURES ENC_TYPE 0 104,813, % 6 PROCEDURES ENCOUNTERID 0 104,813, % 43,405,43 5 PROCEDURES PATID 0 104,813, % 3,508,276 PROCEDURES PROCEDURESID 0 104,813, % 104,813,8 62 PROCEDURES PX 0 104,813, % 33,989 PROCEDURES PX_DATE 0 104,813, % 5,272 PROCEDURES SITEID 0 104,813, % 5 SURGICAL_HISTORY PX_DATE 1,595,510 2,984, % 41,963 SURGICAL_HISTORY PATID 0 2,984, % 763,953 SURGICAL_HISTORY PX 0 2,984, % 9,121 CDM Page 138

139 SURGICAL_HISTORY PX_DESCRIPTION 0 2,984, % 9,257 SURGICAL_HISTORY PX_TYPE 0 2,984, % 3 SURGICAL_HISTORY SITEID 0 2,984, % 2 SURGICAL_HISTORY SURGICAL_HISTORY_DATE 0 2,984, % 3,962 SURGICAL_HISTORY SURGICAL_HX_SOURCE 0 2,984, % 1 SURGICAL_HISTORY SURGICALHISTORYID 0 2,984, % 2,984,466 VITAL BP_POSITION 29,175,653 38,222, % 4 VITAL TOBACCO_TYPE 18,323,855 38,222, % 8 VITAL HT 16,199,588 38,222, % 8,036 VITAL SMOKING 16,077,471 38,222, % 11 VITAL ORIGINAL_BMI 13,462,431 38,222, % 24,164 VITAL TOBACCO 12,461,586 38,222, % 9 VITAL DIASTOLIC 10,345,814 38,222, % 799 VITAL SYSTOLIC 10,345,720 38,222, % 516 VITAL WT 9,938,593 38,222, % 22,680 VITAL ENCOUNTERID 373,206 38,222, % 28,003,27 9 VITAL MEASURE_TIME 115,842 38,222, % 1,693 VITAL MEASURE_DATE 0 38,222, % 6,328 VITAL PATID 0 38,222, % 3,366,681 VITAL SITEID 0 38,222, % 4 VITAL VITAL_SOURCE 0 38,222, % 2 VITAL VITALID 0 38,222, % 38,222,91 0 CDM Page 139

140 Appendix D: Patient Distribution by Clinic's State Health Systems Clinic Sites Cities States Patients ,582,870 CDM Page 140

141 Appendix E: Selected Patient Characteristics Patients with Ambulatory Visit,Dental encounter(s) between 1/1/2012 and 3/31/2017 Patients by sex and selected condition: Sex Patients % Female 2,070, % Male 1,611, % No information % Unknown % Total 3,682, % Patients 18 and older by Condition Condition Patients % Diabetic (Type I or II) 262, % Diabetic Type I 12, % Diabetic Type II 250, % Obese 878, % Obese & Diabetic (Type I or II) 149, % Alpha % Total Adults 2,755, % CDM Page 141

142 Patients by Race and Hispanic Ethnicity Race \ Hispanic Ethnicity No Yes Unknown No information Refuse to answer Total % White 1,328,773 1,007,516 27,120 19,494 23,825 2,406, % Black or African American 660,392 34,475 7,717 7,731 17, , % Asian 106,016 2,801 2,838 1,352 3, , % Unknown 31,387 71,283 49, , % Refuse to answer 24,899 68, , , % No Information 15,149 29,413 3,742 24,906 3,370 76, % Multiple race 27,826 21, ,926 52, % Native Hawaiian or Other Pacific Islander 15,162 4, ,600 21, % American Indian or Alaskan Native 13,791 9, , % Other , % Total 2,224,071 1,249,900 93,673 54,510 60,440 3,682, % Age Category Patients % % 60.4% 33.9% 2.5% 1.5% 1.6% 100.0% Unknown 10 or less 0.0% , % , % , % , % , % , % , % , % , % , % % Total 3,682, % CDM Page 142

143 Patients by their most recent federal poverty level FPL Category Patients % % and below 1,913, % % 361, % % 141, % 4. Over 200% 297, % 5. Unknown 968, % Total Patients 3,682, % Patients by payer type on most recent visit Payer Type Patients % Medicaid 1,449, % Uninsured 1,024, % Private Insurance 690, % Medicare 263, % Other Public Payer 255, % Total Patients 3,682, % CDM Page 143

144 Patients with Ambulatory Visit,Dental encounter(s) between 1/1/2012 and 3/31/2017 Patients by primary language - Top 10 Primary Language Patients % English 2,742, % Spanish 720, % Unknown 78, % Other language 65, % Somali 21, % Vietnamese 15, % Arabic 11, % Russian 11, % Creole 6, % Nepali 6, % French Creole 3, % Haitian Total Patients 3,682, % CDM Page 144

145 Patients with Ambulatory Visit,Dental encounter(s) between 1/1/2012 and 3/31/2017 Top 15 Encounter Diagnoses Top 15 Procedure Orders DX Coding System Encounter Diagnosis Distinct Patients PX Coding System Procedure Order Distinct Patients Z23 10 Encounter for immunization 724, C4 Compre Metab Panel 1,082,517 V Vaccin for influenza 484, C4 Cbc With Auto Diff 1,076,538 V Routin child health exam 475, C4 Office Visit, Expanded Prob Foc- Estab 975,330 V Routine medical exam 470, C4 Lipid Panel 943,100 Z Encntr for general adult medical exam w/o abnormal findings 376, C4 Thyroid Stimulating Hormone (Tsh) 858,467 V Dental examination 370, C4 Hemoglobin, Glycosylated (A1c) 725,978 I10 10 Essential (primary) hypertension 355, C4 Immunization Admin 668,532 Z Encntr for routine child health exam w/o abnormal findings 343, C4 Collection, Venous Blood, Venipuncture 615,079 Z Encounter for dental exam and cleaning w/o abnormal findings 309, C4 Tdap (7 + Years) 498, Hypertension NOS 293, C4 Urinalysis, Dipstick, Nonauto, W/O Micro 495, Acute uri NOS 281, F C2 Body Mass Index Docd 478,480 Z Encounter for screening for other disorder 275, C4 Influenza Virus Vaccine, 3+ Years, Im Use 476,771 V Routine gyn examination 265, C4 Office Visit, Problem Focused- Estab 466, Hyperlipidemia NEC/NOS 246, C4 Office Visit, Detailed- Estab 431,513 V Vaccination for DTP-DTaP 228,898 D0150 OT Comprehensive Oral Evaluation - New Or Established Patient 411,901 CDM Page 145

146 Patients with Ambulatory Visit,Dental encounter(s) between 1/1/2012 and 3/31/2017 Last BMI - Classification Patients by BMI Classification - Last BMI Distinct Patients b. Underweight < , % c. Normal , % d. Overweight , % e. Obesity Class I , % f. Obesity Class II , % g. Extreme Obesity >= , % z. Not Measured 560, % Total Patients 3,682,594 % CDM Page 146

147 Patients with Ambulatory Visit,Dental encounter(s) between 1/1/2012 and 3/31/2017 Last Diastolic Patients by Last Diastolic BP Measure Distinct Patients a. Under 51 40, % b , % c , % d ,053, % e , % f , % g , % k. Over % z. Not Measured 614, % Total Patients 3,682,594 % CDM Page 147

148 Last Smoking Status Patients by last Smoking Status Distinct Patients Never smoker [04] 1,851, % No information [NI] 778, % Unknown if ever smoked [06] % 300, % Former smoker [03] 287, % Current every day smoker [01] Smoker, current status unknown [05] 272, % 72, % Other [OT] 54, % Current some day smoker [02] 48, % Light tobacco smoker [08] 14, % Heavy tobacco smoker [07] 2, % Unknown [UN] % Total Patients 3,682,594 Last Tobacco Status Patients by last Tobacco Status Distinct Patients Never [02] 1,303, % No information [NI] 786, % Unknown [UN] 602, % Current user [01] 550, % Quit/former user [03] 287, % Other [OT] 81, % Passive or environmental exposure [04] % 70, % Not asked [06] % Total Patients 3,682,594 CDM Page 148